Provider Demographics
NPI:1508022302
Name:WILLIS, BRANDYN (LPC)
Entity Type:Individual
Prefix:
First Name:BRANDYN
Middle Name:
Last Name:WILLIS
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6262 S SHERIDAN RD
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74133-4055
Mailing Address - Country:US
Mailing Address - Phone:918-492-8200
Mailing Address - Fax:918-493-3268
Practice Address - Street 1:6125 S SHERIDAN RD
Practice Address - Street 2:SUITE D
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74133-4056
Practice Address - Country:US
Practice Address - Phone:918-585-3085
Practice Address - Fax:918-495-3713
Is Sole Proprietor?:No
Enumeration Date:2008-07-31
Last Update Date:2008-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional