Provider Demographics
NPI:1306016118
Name:WILLIS, DIANE JANICE (PHD)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:JANICE
Last Name:WILLIS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4520 RIDGELINE DR
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73072-1729
Mailing Address - Country:US
Mailing Address - Phone:405-364-9091
Mailing Address - Fax:
Practice Address - Street 1:4520 RIDGELINE DR
Practice Address - Street 2:
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73072-1729
Practice Address - Country:US
Practice Address - Phone:405-364-9091
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-07
Last Update Date:2008-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK164103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1202405Medicaid