1629170550 NPI number — MRS. LORIE DORHOLT TANDY MS, LPC, LLC

Table of content: MRS. LORIE DORHOLT TANDY MS, LPC, LLC (NPI 1629170550)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629170550 NPI number — MRS. LORIE DORHOLT TANDY MS, LPC, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DORHOLT TANDY
Provider First Name:
LORIE
Provider Middle Name:
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MS, LPC, LLC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
DORHOLT
Provider Other First Name:
AMY
Provider Other Middle Name:
LORIE
Provider Other Name Prefix Text:
MRS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
MS, LPC
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1629170550
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/13/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4870 S LEWIS AVE
Provider Second Line Business Mailing Address:
SUITE 115
Provider Business Mailing Address City Name:
TULSA
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
74105-5151
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
918-494-5659
Provider Business Mailing Address Fax Number:
918-551-6619

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4870 S LEWIS AVE
Provider Second Line Business Practice Location Address:
SUITE 115
Provider Business Practice Location Address City Name:
TULSA
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
74105-5177
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
918-494-5659
Provider Business Practice Location Address Fax Number:
918-551-6619
Provider Enumeration Date:
09/01/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X , with the licence number:  2039 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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