Healthcare Provider Details

I. General information

NPI: 1750719886
Provider Name (Legal Business Name): MARYLEE GASKINS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/29/2013
Last Update Date: 10/29/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

302 E 19TH ST
OWASSO OK
74055-4612
US

IV. Provider business mailing address

302 E 19TH ST
OWASSO OK
74055-4612
US

V. Phone/Fax

Practice location:
  • Phone: 918-272-5326
  • Fax:
Mailing address:
  • Phone: 918-272-5326
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code323P00000X
TaxonomyPsychiatric Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: MARYLEE NANNELL GASKINS
Title or Position: SELF
Credential:
Phone: 918-272-5326