Provider Demographics
NPI:1033520549
Name:CULLEY-GARDNER, JANIS
Entity Type:Individual
Prefix:
First Name:JANIS
Middle Name:
Last Name:CULLEY-GARDNER
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 1:445 NW 115TH ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73114-6732
Mailing Address - Country:US
Mailing Address - Phone:405-650-2120
Mailing Address - Fax:
Practice Address - Street 1:7250 NW EXPRESSWAY
Practice Address - Street 2:200
Practice Address - City:OKC
Practice Address - State:OK
Practice Address - Zip Code:73122-1522
Practice Address - Country:US
Practice Address - Phone:405-525-0452
Practice Address - Fax:405-525-0515
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-19
Last Update Date:2014-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK0117101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health