Healthcare Provider Details

I. General information

NPI: 1255538237
Provider Name (Legal Business Name): GAYLA BETH BRANSCUM LMHP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: GAYLA BETH CARTER

II. Dates (important events)

Enumeration Date: 07/02/2007
Last Update Date: 03/21/2024
Certification Date: 03/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

527 W 3RD ST
KONAWA OK
74849-1415
US

IV. Provider business mailing address

527 W 3RD ST
KONAWA OK
74849-1415
US

V. Phone/Fax

Practice location:
  • Phone: 580-925-3286
  • Fax: 580-925-2362
Mailing address:
  • Phone: 580-925-3286
  • Fax: 580-925-2362

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLPC02906
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: