MEDICARE: MS. LISA DEE GARDNER- RUMINER M.ED

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	101YM0800X	Mental Health Counselor	2492	OK
2	103G00000X	Clinical Neuropsychologist	2492	OK
3	101YP2500X	Professional Counselor

General Provider Information

NPI Number	:	1669528733
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. LISA DEE GARDNER- RUMINER M.ED

Provider Business Mailing Address
First Line	:	4436 NW 50TH ST
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73112-2212
Country	:	US
Telephone Number	:	405-272-0660
Fax Number	:

Provider Business Practice Location Address
First Line	:	711 STANTON L YOUNG BLVD STE 430
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73104-5022
Country	:	US
Telephone Number	:	405-271-6434
Fax Number	:	405-271-6264

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

Provider Enumeration Date	:	01/25/2007
Last Update Date	:	02/18/2020

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