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General NPI Number Information
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NPI Number | 1255536454
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Entity Type | Individual
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Provider Name | GARY NELSON
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Gender | Male
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Dates
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Enumeration Date | 06/18/2007
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Last Update Date | 10/15/2008
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Provider Practice Location Address
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Address Line | RR 3 BOX 1230
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City | WILBURTON
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State | OK
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Zip | 74578-9523
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Country | US
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Telephone | 918-465-3854
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Fax |
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Provider Business Mailing Address
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Address Line | RR 3 BOX 1230
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City | WILBURTON
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State | OK
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Zip | 74578-9523
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Country | US
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Telephone | 918-465-3854
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number |
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License Number State |
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