Provider Demographics
NPI:1629738695
Name:GAVIN, MIGUEL ROMEL II
Entity Type:Individual
Prefix:
First Name:MIGUEL
Middle Name:ROMEL
Last Name:GAVIN
Suffix:II
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:231 E APACHE ST
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74106-3701
Mailing Address - Country:US
Mailing Address - Phone:918-810-0275
Mailing Address - Fax:
Practice Address - Street 1:240 E APACHE ST
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74106-3702
Practice Address - Country:US
Practice Address - Phone:918-810-0275
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-17
Last Update Date:2021-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKG083673012101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKN00001838-02OtherCOMMUNITY CARE