Provider Demographics
NPI:1164297651
Name:CALLISON, AMY LEANNE
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:LEANNE
Last Name:CALLISON
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 1:102 N DENVER AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74103-1806
Mailing Address - Country:US
Mailing Address - Phone:918-582-1200
Mailing Address - Fax:
Practice Address - Street 1:102 N DENVER AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74103-1806
Practice Address - Country:US
Practice Address - Phone:918-852-1200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-15
Last Update Date:2024-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
175T00000X
OK134688171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1457537037Medicaid