Provider Demographics
NPI:1912131996
Name:GATES, MARY ELIZABETH (PHD)
Entity type:Individual
Prefix:DR
First Name:MARY
Middle Name:ELIZABETH
Last Name:GATES
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18905 E 22 RD
Mailing Address - Street 2:
Mailing Address - City:LAVERNE
Mailing Address - State:OK
Mailing Address - Zip Code:73848-4834
Mailing Address - Country:US
Mailing Address - Phone:580-216-3847
Mailing Address - Fax:
Practice Address - Street 1:18905 E 22 RD
Practice Address - Street 2:
Practice Address - City:LAVERNE
Practice Address - State:OK
Practice Address - Zip Code:73848-4834
Practice Address - Country:US
Practice Address - Phone:580-216-3847
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-06
Last Update Date:2024-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK10474101YP2500X, 101Y00000X
OK0106101YM0800X
CO00005033101YP2500X
OK2167101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK2009294074AMedicaid