Healthcare Provider Details

I. General information

NPI: 1033520549
Provider Name (Legal Business Name): JANIS CULLEY-GARDNER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/19/2014
Last Update Date: 05/19/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7250 NW EXPRESSWAY 200
OKC OK
73122-1522
US

IV. Provider business mailing address

445 NW 115TH ST
OKLAHOMA CITY OK
73114-6732
US

V. Phone/Fax

Practice location:
  • Phone: 405-525-0452
  • Fax: 405-525-0515
Mailing address:
  • Phone: 405-650-2120
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0117
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: