Healthcare Provider Details

I. General information

NPI: 1104434349
Provider Name (Legal Business Name): KARLEEANN GRAY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2020
Last Update Date: 07/14/2020
Certification Date: 07/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1012 NW GRAND BLVD
OKLAHOMA CITY OK
73118-6000
US

IV. Provider business mailing address

15520 NE 164TH ST
JONES OK
73049-8905
US

V. Phone/Fax

Practice location:
  • Phone: 405-594-8336
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberBACB594598
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: