Provider Demographics
NPI:1679096952
Name:BARNES, GABRIELLE EVANGELINE (MCP, LADC/MH)
Entity Type:Individual
Prefix:
First Name:GABRIELLE
Middle Name:EVANGELINE
Last Name:BARNES
Suffix:
Gender:F
Credentials:MCP, LADC/MH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:620 W GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:PONCA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:74601-5123
Mailing Address - Country:US
Mailing Address - Phone:580-762-1462
Mailing Address - Fax:
Practice Address - Street 1:200 WHITE EAGLE DR
Practice Address - Street 2:
Practice Address - City:PONCA CITY
Practice Address - State:OK
Practice Address - Zip Code:74601-8315
Practice Address - Country:US
Practice Address - Phone:580-762-3421
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-19
Last Update Date:2024-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
OK1421101YA0400X, 101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101Y00000XBehavioral Health & Social Service ProvidersCounselor