Provider Demographics
NPI:1063606085
Name:GREGORY, ARDEL LYNN (MS)
Entity type:Individual
Prefix:MS
First Name:ARDEL
Middle Name:LYNN
Last Name:GREGORY
Suffix:
Gender:F
Credentials:MS
Other - Prefix:MS
Other - First Name:DEL
Other - Middle Name:LYNN
Other - Last Name:MORGAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS
Mailing Address - Street 1:4870 S LEWIS AVE
Mailing Address - Street 2:SUITE 190
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74105-5151
Mailing Address - Country:US
Mailing Address - Phone:918-628-7277
Mailing Address - Fax:918-742-7677
Practice Address - Street 1:4870 S LEWIS AVE
Practice Address - Street 2:SUITE 190
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74105-5151
Practice Address - Country:US
Practice Address - Phone:918-628-7277
Practice Address - Fax:918-742-7677
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-03
Last Update Date:2007-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1048101YP2500X
OK183106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist