Provider Demographics
NPI:1851042998
Name:GAITHER, RYAN JOE
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:JOE
Last Name:GAITHER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1710
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:OK
Mailing Address - Zip Code:73439-1710
Mailing Address - Country:US
Mailing Address - Phone:580-564-7374
Mailing Address - Fax:
Practice Address - Street 1:2502 CROSSROADS DR STE A
Practice Address - Street 2:
Practice Address - City:ARDMORE
Practice Address - State:OK
Practice Address - Zip Code:73401-2503
Practice Address - Country:US
Practice Address - Phone:580-226-5209
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-11
Last Update Date:2022-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK731562950Medicaid