Provider Demographics
NPI:1285805614
Name:WICKLIFFE-HERRON, PORTIA KAY (NCC, LPC, LBP)
Entity type:Individual
Prefix:MS
First Name:PORTIA
Middle Name:KAY
Last Name:WICKLIFFE-HERRON
Suffix:
Gender:F
Credentials:NCC, LPC, LBP
Other - Prefix:
Other - First Name:PORTIA
Other - Middle Name:KAY
Other - Last Name:KELLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:101 S MOORE AVE
Mailing Address - Street 2:
Mailing Address - City:CLAREMORE
Mailing Address - State:OK
Mailing Address - Zip Code:74017-5047
Mailing Address - Country:US
Mailing Address - Phone:918-342-6460
Mailing Address - Fax:918-342-6665
Practice Address - Street 1:101 S MOORE AVE
Practice Address - Street 2:
Practice Address - City:CLAREMORE
Practice Address - State:OK
Practice Address - Zip Code:74017-5047
Practice Address - Country:US
Practice Address - Phone:918-342-6460
Practice Address - Fax:918-342-6665
Is Sole Proprietor?:No
Enumeration Date:2008-03-13
Last Update Date:2023-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1233101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health