Provider Demographics
NPI:1073108619
Name:GILBREATH, TAMARA
Entity Type:Individual
Prefix:
First Name:TAMARA
Middle Name:
Last Name:GILBREATH
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 1:8154 COUNTY ROAD 1470
Mailing Address - Street 2:
Mailing Address - City:APACHE
Mailing Address - State:OK
Mailing Address - Zip Code:73006-6600
Mailing Address - Country:US
Mailing Address - Phone:580-512-5828
Mailing Address - Fax:
Practice Address - Street 1:1202 SW 27TH ST
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73505-7947
Practice Address - Country:US
Practice Address - Phone:580-353-8861
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-05
Last Update Date:2021-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK807224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant