Provider Demographics
NPI:1922390590
Name:SKILLENS, EBONY (LPC)
Entity Type:Individual
Prefix:
First Name:EBONY
Middle Name:
Last Name:SKILLENS
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 1:6028 S 66TH EAST AVE STE 103
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74145-9226
Mailing Address - Country:US
Mailing Address - Phone:918-471-4939
Mailing Address - Fax:844-881-4140
Practice Address - Street 1:6028 S 66TH EAST AVE STE 103
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74145-9226
Practice Address - Country:US
Practice Address - Phone:918-932-8774
Practice Address - Fax:844-881-4140
Is Sole Proprietor?:No
Enumeration Date:2011-05-13
Last Update Date:2020-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKK86000093101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100710510EMedicaid