Healthcare Provider Details

I. General information

NPI: 1467485557
Provider Name (Legal Business Name): GAYLA J WISOR MS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: GAYLA J EASTEP-BIRCH MS

II. Dates (important events)

Enumeration Date: 07/09/2006
Last Update Date: 06/11/2022
Certification Date: 06/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

902 NW 32ND ST
NEWCASTLE OK
73065-6605
US

IV. Provider business mailing address

33432 N COUNTY ROAD 3130
ELMORE CITY OK
73433-8716
US

V. Phone/Fax

Practice location:
  • Phone: 405-527-2424
  • Fax:
Mailing address:
  • Phone: 843-655-1740
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: