Provider Demographics
NPI:1326044397
Name:GARNER, DERRISE L (PSYD)
Entity Type:Individual
Prefix:
First Name:DERRISE
Middle Name:L
Last Name:GARNER
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2650 E 32ND ST STE 221
Mailing Address - Street 2:
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64804-4300
Mailing Address - Country:US
Mailing Address - Phone:417-623-1381
Mailing Address - Fax:417-623-0457
Practice Address - Street 1:2 N MAIN ST STE 505
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:OK
Practice Address - Zip Code:74354-6312
Practice Address - Country:US
Practice Address - Phone:877-540-0202
Practice Address - Fax:417-623-0457
Is Sole Proprietor?:No
Enumeration Date:2005-06-24
Last Update Date:2009-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1031103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200248420AMedicaid