Provider Demographics
NPI:1275083123
Name:GASPAROTTO, REBECCA
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:GASPAROTTO
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:PO BOX 179
Mailing Address - Street 2:
Mailing Address - City:STIGLER
Mailing Address - State:OK
Mailing Address - Zip Code:74462-0179
Mailing Address - Country:US
Mailing Address - Phone:918-967-3368
Mailing Address - Fax:918-967-3351
Practice Address - Street 1:1630 S KERR BLVD
Practice Address - Street 2:
Practice Address - City:SALLISAW
Practice Address - State:OK
Practice Address - Zip Code:74955-7240
Practice Address - Country:US
Practice Address - Phone:918-967-7902
Practice Address - Fax:918-790-2763
Is Sole Proprietor?:No
Enumeration Date:2016-10-04
Last Update Date:2022-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK7833104100000X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200971680AMedicaid