Healthcare Provider Details

I. General information

NPI: 1255683611
Provider Name (Legal Business Name): TINA MICHELLE GRAY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: TINA MICHELLE REED

II. Dates (important events)

Enumeration Date: 10/10/2012
Last Update Date: 10/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

721 SOUTH WEST FORTUNE ST
LANGSTON OK
73050-0953
US

IV. Provider business mailing address

PO BOX 953 721 SW FORTUNE STREET
LANGSTON OK
73050-0953
US

V. Phone/Fax

Practice location:
  • Phone: 405-513-1353
  • Fax:
Mailing address:
  • Phone: 405-513-1353
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: