Healthcare Provider Details

I. General information

NPI: 1124619655
Provider Name (Legal Business Name): GREGORY KIRBY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/28/2021
Last Update Date: 04/03/2026
Certification Date: 04/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11680 S 153RD WEST AVE
SAPULPA OK
74066-8564
US

IV. Provider business mailing address

11680 S 153RD WEST AVE
SAPULPA OK
74066-8564
US

V. Phone/Fax

Practice location:
  • Phone: 918-639-4684
  • Fax: 918-512-6320
Mailing address:
  • Phone: 918-512-6273
  • Fax: 918-512-6320

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code374K00000X
TaxonomyReligious Nonmedical Practitioner
License Number
License Number StateNULL
# 3
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: