Provider Demographics
NPI:1063817286
Name:DATTALA, LACY (LPC)
Entity Type:Individual
Prefix:
First Name:LACY
Middle Name:
Last Name:DATTALA
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:LACY
Other - Last Name:DATTALA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2512 E 71ST ST STE H
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74136-5575
Mailing Address - Country:US
Mailing Address - Phone:918-510-2170
Mailing Address - Fax:
Practice Address - Street 1:2512 E 71ST ST STE H
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136-5575
Practice Address - Country:US
Practice Address - Phone:918-510-2170
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-30
Last Update Date:2023-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKLPC06561101YM0800X
101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health