Provider Demographics
NPI:1306245378
Name:GATES-ROBIN, MARIAM
Entity type:Individual
Prefix:
First Name:MARIAM
Middle Name:
Last Name:GATES-ROBIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1985 W 33RD ST
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73013-3875
Mailing Address - Country:US
Mailing Address - Phone:405-625-0862
Mailing Address - Fax:405-285-6814
Practice Address - Street 1:1985 W 33RD ST
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73013
Practice Address - Country:US
Practice Address - Phone:405-625-0862
Practice Address - Fax:405-285-6814
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-15
Last Update Date:2018-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK6319101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1306245378Medicaid