Healthcare Provider Details

I. General information

NPI: 1730438342
Provider Name (Legal Business Name): GORDON KEITH HARLIN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/29/2012
Last Update Date: 09/06/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

619 N MAIN
MUSKOGEE OK
74401
US

IV. Provider business mailing address

619 N MAIN
MUSKOGEE OK
74401
US

V. Phone/Fax

Practice location:
  • Phone: 918-682-8407
  • Fax: 918-687-0976
Mailing address:
  • Phone: 918-682-8407
  • Fax: 918-687-0976

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: