Healthcare Provider Details

I. General information

NPI: 1376331504
Provider Name (Legal Business Name): MATTHEW GUMM
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/28/2025
Last Update Date: 04/28/2025
Certification Date: 04/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

520 POINTE PARKWAY BLVD
YUKON OK
73099-0600
US

IV. Provider business mailing address

520 POINTE PARKWAY BLVD
YUKON OK
73099-0600
US

V. Phone/Fax

Practice location:
  • Phone: 405-805-6403
  • Fax:
Mailing address:
  • Phone: 405-805-6403
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: