Provider Demographics
NPI:1073626545
Name:MATTOX, LARA MAE (PHD)
Entity type:Individual
Prefix:DR
First Name:LARA
Middle Name:MAE
Last Name:MATTOX
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3015 EAST SKELLY DRIVE
Mailing Address - Street 2:SUITE 305
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74105-6317
Mailing Address - Country:US
Mailing Address - Phone:918-392-4866
Mailing Address - Fax:918-392-4867
Practice Address - Street 1:3015 EAST SKELLY DRIVE
Practice Address - Street 2:SUITE 305
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74105-6317
Practice Address - Country:US
Practice Address - Phone:918-392-4866
Practice Address - Fax:918-392-4867
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-17
Last Update Date:2011-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR06-09P103TC0700X
OK1022103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical