Provider Demographics
NPI:1053331280
Name:WILLIS, JANET GAYLE (PHD)
Entity type:Individual
Prefix:DR
First Name:JANET
Middle Name:GAYLE
Last Name:WILLIS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:JANET
Other - Middle Name:HEATH
Other - Last Name:WILLIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4815 S HARVARD AVE
Mailing Address - Street 2:SUITE 525
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74135-3055
Mailing Address - Country:US
Mailing Address - Phone:918-619-9060
Mailing Address - Fax:918-289-0436
Practice Address - Street 1:4815 S HARVARD AVE
Practice Address - Street 2:SUITE 525
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74135-3055
Practice Address - Country:US
Practice Address - Phone:918-619-9060
Practice Address - Fax:918-289-0436
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2015-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK566103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100839210BMedicaid
OK600522417OtherMEDICARE PTAN
OK10083921AMedicaid
OK100839210BMedicaid