Provider Demographics
NPI:1346012879
Name:ROYBAL-GOWER, REBECCA CINNAMON
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:CINNAMON
Last Name:ROYBAL-GOWER
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 1:2105 BRENDA AVE
Mailing Address - Street 2:
Mailing Address - City:TAHLEQUAH
Mailing Address - State:OK
Mailing Address - Zip Code:74464-6321
Mailing Address - Country:US
Mailing Address - Phone:191-884-0939
Mailing Address - Fax:
Practice Address - Street 1:17675 S MUSKOGEE AVE
Practice Address - Street 2:
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74464-5492
Practice Address - Country:US
Practice Address - Phone:918-453-5555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-27
Last Update Date:2023-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)
No103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical