MEDICARE: EBONY SKILLENS LPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	K86000093	OK

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1922390590
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EBONY SKILLENS LPC

Provider Business Mailing Address
First Line	:	6028 S 66TH EAST AVE STE 103
Second Line	:
City	:	TULSA
State	:	OK
Zip	:	74145-9226
Country	:	US
Telephone Number	:	918-471-4939
Fax Number	:	844-881-4140

Provider Business Practice Location Address
First Line	:	6028 S 66TH EAST AVE STE 103
Second Line	:
City	:	TULSA
State	:	OK
Zip	:	74145-9226
Country	:	US
Telephone Number	:	918-932-8774
Fax Number	:	844-881-4140

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/13/2011
Last Update Date	:	06/14/2024

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