Provider Demographics
NPI:1780902114
Name:WICKLIFFE, SANDRA LEE
Entity type:Individual
Prefix:MS
First Name:SANDRA
Middle Name:LEE
Last Name:WICKLIFFE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4300 S HARVARD AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74135-2619
Mailing Address - Country:US
Mailing Address - Phone:918-584-7500
Mailing Address - Fax:918-585-2876
Practice Address - Street 1:4300 S HARVARD AVE.
Practice Address - Street 2:SUITE 100
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74135
Practice Address - Country:US
Practice Address - Phone:918-584-7500
Practice Address - Fax:918-585-2676
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-10
Last Update Date:2010-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker