Provider Demographics
NPI:1639447394
Name:GAINES, HENRY LEE JR (CM)
Entity Type:Individual
Prefix:MR
First Name:HENRY
Middle Name:LEE
Last Name:GAINES
Suffix:JR
Gender:M
Credentials:CM
Other - Prefix:MR
Other - First Name:HANK
Other - Middle Name:
Other - Last Name:COLEMAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:3621 N KELLEY AVE
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73111-4520
Mailing Address - Country:US
Mailing Address - Phone:405-524-5525
Mailing Address - Fax:
Practice Address - Street 1:3621 N KELLEY AVE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73111-4520
Practice Address - Country:US
Practice Address - Phone:405-524-5525
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-09
Last Update Date:2013-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK251B00000X
101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)