Provider Demographics
NPI:1073962569
Name:JANET WILLIS, PH.D., PLLC
Entity Type:Organization
Organization Name:JANET WILLIS, PH.D., PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/RN/PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JANET
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIS
Authorized Official - Suffix:
Authorized Official - Credentials:RN, PHD
Authorized Official - Phone:918-640-2632
Mailing Address - Street 1:4815 S HARVARD AVE
Mailing Address - Street 2:SUITE 525
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74135-3055
Mailing Address - Country:US
Mailing Address - Phone:918-619-9060
Mailing Address - Fax:918-289-0436
Practice Address - Street 1:4815 S HARVARD AVE
Practice Address - Street 2:SUITE 525
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74135-3055
Practice Address - Country:US
Practice Address - Phone:918-619-9060
Practice Address - Fax:918-289-0436
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-06
Last Update Date:2016-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK566251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK10083921AMedicaid