Provider Demographics
NPI:1306431747
Name:ALLISON, MICAH JAY (MS LPC-C)
Entity type:Individual
Prefix:
First Name:MICAH
Middle Name:JAY
Last Name:ALLISON
Suffix:
Gender:M
Credentials:MS LPC-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1140 MAYBERRY DR
Mailing Address - Street 2:
Mailing Address - City:TAHLEQUAH
Mailing Address - State:OK
Mailing Address - Zip Code:74464-4603
Mailing Address - Country:US
Mailing Address - Phone:918-453-1108
Mailing Address - Fax:918-453-1108
Practice Address - Street 1:1140 MAYBERRY DR
Practice Address - Street 2:
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74464-4603
Practice Address - Country:US
Practice Address - Phone:918-453-1108
Practice Address - Fax:918-453-1108
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-08
Last Update Date:2021-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty