Provider Demographics
NPI:1528127388
Name:O'BRYAN, CAROL ELLISE (LMFT)
Entity type:Individual
Prefix:
First Name:CAROL
Middle Name:ELLISE
Last Name:O'BRYAN
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 S GARNETT RD
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74128-1805
Mailing Address - Country:US
Mailing Address - Phone:918-438-4257
Mailing Address - Fax:
Practice Address - Street 1:301 S POPLAR AVE
Practice Address - Street 2:
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74012-8396
Practice Address - Country:US
Practice Address - Phone:918-251-1662
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-07
Last Update Date:2012-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK895106H00000X
MO2007002866106H00000X
MO2006029726101YP2500X
OK4025101YP2500X
TN798106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional