MEDICARE: MARK GUNN CADC

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	101YA0400X	Addiction (Substance Use Disorder) Counselor

General Provider Information

NPI Number	:	1427278431
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARK GUNN CADC

Provider Business Mailing Address
First Line	:	1815 W OKLAHOMA AVE
Second Line	:
City	:	GUTHRIE
State	:	OK
Zip	:	73044-2238
Country	:	US
Telephone Number	:	405-293-9159
Fax Number	:

Provider Business Practice Location Address
First Line	:	1501 NE 11TH ST
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73117-2605
Country	:	US
Telephone Number	:	405-230-1129
Fax Number	:	405-424-2810

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

Provider Enumeration Date	:	05/01/2007
Last Update Date	:	07/08/2007

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