Provider Demographics
NPI:1558632059
Name:ANDERSON, GAYLA BURGESS
Entity Type:Individual
Prefix:
First Name:GAYLA
Middle Name:BURGESS
Last Name:ANDERSON
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 2077
Mailing Address - Street 2:
Mailing Address - City:TAHLEQUAH
Mailing Address - State:OK
Mailing Address - Zip Code:74465-2077
Mailing Address - Country:US
Mailing Address - Phone:918-931-8825
Mailing Address - Fax:
Practice Address - Street 1:822 S MUSKOGEE AVE
Practice Address - Street 2:
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74464-4720
Practice Address - Country:US
Practice Address - Phone:918-931-8825
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-16
Last Update Date:2012-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor