Provider Demographics
NPI:1528472990
Name:GILBERT, CARLY REID
Entity type:Individual
Prefix:
First Name:CARLY
Middle Name:REID
Last Name:GILBERT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CARLY
Other - Middle Name:REID
Other - Last Name:GILBERT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:9777 HICKORY HILL RD
Mailing Address - Street 2:
Mailing Address - City:SAPULPA
Mailing Address - State:OK
Mailing Address - Zip Code:74066-1200
Mailing Address - Country:US
Mailing Address - Phone:405-414-5072
Mailing Address - Fax:
Practice Address - Street 1:5555 S LEWIS AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74105-7104
Practice Address - Country:US
Practice Address - Phone:918-779-4556
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-13
Last Update Date:2014-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator