MEDICARE: MR. FRED LEE MCGINN IV

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101Y00000X	Counselor	4800	OK
2	101YA0400X	Addiction (Substance Use Disorder) Counselor	1003	OK
3	101Y00000X	Counselor

General Provider Information

NPI Number	:	1336467299
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. FRED LEE MCGINN IV

Provider Business Mailing Address
First Line	:	14836 GAMBELS TRAIL DR
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73134-5226
Country	:	US
Telephone Number	:	405-509-5056
Fax Number	:

Provider Business Practice Location Address
First Line	:	14836 GAMBELS TRAIL DR
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73134-5226
Country	:	US
Telephone Number	:	405-509-5056
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/17/2010
Last Update Date	:	05/11/2026

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