Provider Demographics
NPI:1689958894
Name:MOORE, ODETTA MARIA (LPC)
Entity Type:Individual
Prefix:MS
First Name:ODETTA
Middle Name:MARIA
Last Name:MOORE
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:PO BOX 701111
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74170-1111
Mailing Address - Country:US
Mailing Address - Phone:918-406-7195
Mailing Address - Fax:
Practice Address - Street 1:5310 E 31ST ST
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74135-5018
Practice Address - Country:US
Practice Address - Phone:918-600-3100
Practice Address - Fax:918-560-1399
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-06
Last Update Date:2021-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YP2500X
OK6275101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional