Provider Demographics
NPI:1417312182
Name:TOLLETTE, JOHN WILLIAM (LPC)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:WILLIAM
Last Name:TOLLETTE
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1405 E MOSES
Mailing Address - Street 2:
Mailing Address - City:CUSHING
Mailing Address - State:OK
Mailing Address - Zip Code:74023
Mailing Address - Country:US
Mailing Address - Phone:918-225-5600
Mailing Address - Fax:918-225-3026
Practice Address - Street 1:1405 E MOSES
Practice Address - Street 2:
Practice Address - City:CUSHING
Practice Address - State:OK
Practice Address - Zip Code:74023
Practice Address - Country:US
Practice Address - Phone:918-225-5600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-23
Last Update Date:2015-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1803101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100686560AMedicaid