Provider Demographics
NPI:1790205094
Name:ELLIS, DESTINY LYN (LPC)
Entity type:Individual
Prefix:
First Name:DESTINY
Middle Name:LYN
Last Name:ELLIS
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 1:8306 E HIGHWAY 88
Mailing Address - Street 2:
Mailing Address - City:OOLOGAH
Mailing Address - State:OK
Mailing Address - Zip Code:74053-6396
Mailing Address - Country:US
Mailing Address - Phone:918-728-9516
Mailing Address - Fax:
Practice Address - Street 1:12834 OLD U.S. 169
Practice Address - Street 2:
Practice Address - City:OOLOGAH
Practice Address - State:OK
Practice Address - Zip Code:74053
Practice Address - Country:US
Practice Address - Phone:918-695-2059
Practice Address - Fax:918-221-7975
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-27
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X, 390200000X
OK10335101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program