Provider Demographics
NPI:1114341914
Name:OXENDALE, GARY L (LMSW)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:L
Last Name:OXENDALE
Suffix:
Gender:M
Credentials:LMSW
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 3
Mailing Address - Street 2:
Mailing Address - City:WHITEHALL
Mailing Address - State:MI
Mailing Address - Zip Code:49461-0003
Mailing Address - Country:US
Mailing Address - Phone:231-740-9050
Mailing Address - Fax:
Practice Address - Street 1:125 E SOUTHERN AVE
Practice Address - Street 2:
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49442-5041
Practice Address - Country:US
Practice Address - Phone:231-726-3582
Practice Address - Fax:231-722-6933
Is Sole Proprietor?:No
Enumeration Date:2014-02-13
Last Update Date:2015-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010832391041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0F16408Medicare PIN