Provider Demographics
NPI:1073956769
Name:RIDEAU, GREGORY DEAUNTRA
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:DEAUNTRA
Last Name:RIDEAU
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 1:3012 SE 21ST ST
Mailing Address - Street 2:
Mailing Address - City:DEL CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73115-1530
Mailing Address - Country:US
Mailing Address - Phone:479-747-9879
Mailing Address - Fax:
Practice Address - Street 1:3012 SE 21ST ST
Practice Address - Street 2:
Practice Address - City:DEL CITY
Practice Address - State:OK
Practice Address - Zip Code:73115-1530
Practice Address - Country:US
Practice Address - Phone:479-747-9879
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-11
Last Update Date:2013-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst