Provider Demographics
NPI:1467882985
Name:ROBERTS, GWENDA LEE
Entity Type:Individual
Prefix:
First Name:GWENDA
Middle Name:LEE
Last Name:ROBERTS
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 1:3508 MALONEY DR
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73121-6656
Mailing Address - Country:US
Mailing Address - Phone:405-427-6381
Mailing Address - Fax:
Practice Address - Street 1:3508 MALONEY DR
Practice Address - Street 2:
Practice Address - City:OKLAHOMA
Practice Address - State:OKLAHOMA
Practice Address - Zip Code:73121
Practice Address - Country:UM
Practice Address - Phone:405-437-6381
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-19
Last Update Date:2013-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK101YM0800X, 101YP1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral