Provider Demographics
NPI:1134349582
Name:MILLICAN, DOROTHY LYNETTE (PHD)
Entity type:Individual
Prefix:DR
First Name:DOROTHY
Middle Name:LYNETTE
Last Name:MILLICAN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:DOROTHY
Other - Middle Name:LYNETTE
Other - Last Name:MILLICAN-WYNN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:P.O. BOX 52135 DOROTHY MILLICAN
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74152-0135
Mailing Address - Country:US
Mailing Address - Phone:918-740-4066
Mailing Address - Fax:918-742-4900
Practice Address - Street 1:THE ELITE MEDICAL CLINIC
Practice Address - Street 2:3336 E 32ND STREET
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74135-4448
Practice Address - Country:US
Practice Address - Phone:918-740-4066
Practice Address - Fax:918-670-7364
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-26
Last Update Date:2024-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK634103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100837450Medicaid