Provider Demographics
NPI:1568870400
Name:DOLEZAL, AMY (LPC)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:DOLEZAL
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 1:710 JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:PERRY
Mailing Address - State:OK
Mailing Address - Zip Code:73077-3223
Mailing Address - Country:US
Mailing Address - Phone:405-205-2077
Mailing Address - Fax:
Practice Address - Street 1:604 S WALNUT ST
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:OK
Practice Address - Zip Code:74074-4222
Practice Address - Country:US
Practice Address - Phone:844-458-2100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-23
Last Update Date:2024-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK6212101YM0800X, 101YP2500X
KS2492101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200551210 BMedicaid