Provider Demographics
NPI:1629569264
Name:TULSA PROFESSIONAL PSYCHOLOGY, PLLC
Entity Type:Organization
Organization Name:TULSA PROFESSIONAL PSYCHOLOGY, PLLC
Other - Org Name:GREEN COUNTRY PSYCHOLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CO-PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:
Authorized Official - Last Name:DOTY
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:918-878-8072
Mailing Address - Street 1:1745 S CANTON AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74112-6937
Mailing Address - Country:US
Mailing Address - Phone:918-878-8072
Mailing Address - Fax:
Practice Address - Street 1:3144 S WINSTON AVE STE A
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74135-2012
Practice Address - Country:US
Practice Address - Phone:918-878-8072
Practice Address - Fax:918-878-8072
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-18
Last Update Date:2018-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1225103TC0700X, 103TH0100X
OK1118103TC0700X, 103TF0200X, 103TH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth ServiceGroup - Multi-Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensicGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200460890BMedicaid
OK200466160AMedicaid