Provider Demographics
NPI:1639576846
Name:GAINES, RONNIE
Entity Type:Individual
Prefix:MR
First Name:RONNIE
Middle Name:
Last Name:GAINES
Suffix:
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 1:7295 W 510
Mailing Address - Street 2:
Mailing Address - City:PRYOR
Mailing Address - State:OK
Mailing Address - Zip Code:74361-7351
Mailing Address - Country:US
Mailing Address - Phone:918-373-4494
Mailing Address - Fax:
Practice Address - Street 1:1217 E 33RD ST
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74105-2017
Practice Address - Country:US
Practice Address - Phone:918-779-4556
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-03
Last Update Date:2014-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist