Healthcare Provider Details

I. General information

NPI: 1336467299
Provider Name (Legal Business Name): MR. FRED LEE MCGINN IV
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/17/2010
Last Update Date: 05/11/2026
Certification Date: 05/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14836 GAMBELS TRAIL DR
OKLAHOMA CITY OK
73134-5226
US

IV. Provider business mailing address

14836 GAMBELS TRAIL DR
OKLAHOMA CITY OK
73134-5226
US

V. Phone/Fax

Practice location:
  • Phone: 405-509-5056
  • Fax:
Mailing address:
  • Phone: 405-509-5056
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number4800
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number1003
License Number StateOK
# 3
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: