Provider Demographics
NPI:1801029715
Name:DYER, ELISSA MARIE (PHD)
Entity Type:Individual
Prefix:DR
First Name:ELISSA
Middle Name:MARIE
Last Name:DYER
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5009 N PENNSYLVANIA AVE STE 116
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73112-8888
Mailing Address - Country:US
Mailing Address - Phone:405-843-1551
Mailing Address - Fax:405-843-1494
Practice Address - Street 1:5009 N PENNSYLVANIA AVE STE 116
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73112-8888
Practice Address - Country:US
Practice Address - Phone:405-843-1551
Practice Address - Fax:405-843-1494
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-25
Last Update Date:2014-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1049103TH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service