Provider Demographics
NPI:1558731000
Name:MARK, NICOLE (LMFT, MA)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:MARK
Suffix:
Gender:F
Credentials:LMFT, MA
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:DAWN
Other - Last Name:WEBB
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMFT
Mailing Address - Street 1:2548 E KENOSHA ST
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74014-6712
Mailing Address - Country:US
Mailing Address - Phone:918-810-3449
Mailing Address - Fax:
Practice Address - Street 1:7320 S YALE AVE STE B
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136-7034
Practice Address - Country:US
Practice Address - Phone:918-992-2335
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-28
Last Update Date:2024-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
OKLMFT01234106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1386079648OtherNPI