Provider Demographics
NPI:1083725915
Name:WILLIS, LORI LYNNE (LPC)
Entity Type:Individual
Prefix:MS
First Name:LORI
Middle Name:LYNNE
Last Name:WILLIS
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:LORI
Other - Middle Name:
Other - Last Name:BOLTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2036 NW 22ND ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73106-1618
Mailing Address - Country:US
Mailing Address - Phone:405-425-0494
Mailing Address - Fax:
Practice Address - Street 1:1105 S.W. 30TH COURT
Practice Address - Street 2:
Practice Address - City:MOORE
Practice Address - State:OK
Practice Address - Zip Code:73160
Practice Address - Country:US
Practice Address - Phone:405-378-2727
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2015-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3048101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health