Provider Demographics
NPI:1750635751
Name:GREENIDGE, GISELLE (MS)
Entity Type:Individual
Prefix:MS
First Name:GISELLE
Middle Name:
Last Name:GREENIDGE
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:602 SW 38TH STREET
Mailing Address - Street 2:
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73505
Mailing Address - Country:US
Mailing Address - Phone:580-248-5780
Mailing Address - Fax:580-357-3867
Practice Address - Street 1:602 SW 38TH STREET
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73505
Practice Address - Country:US
Practice Address - Phone:580-248-5780
Practice Address - Fax:580-357-3867
Is Sole Proprietor?:No
Enumeration Date:2012-10-30
Last Update Date:2013-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health