Provider Demographics
NPI:1821211087
Name:COMMUNITY RESOURCE PROFESSIONALS
Entity Type:Organization
Organization Name:COMMUNITY RESOURCE PROFESSIONALS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL SOCIAL WORKER
Authorized Official - Prefix:MR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW, LADC
Authorized Official - Phone:918-343-3456
Mailing Address - Street 1:304 W WILL ROGERS BLVD
Mailing Address - Street 2:
Mailing Address - City:CLAREMORE
Mailing Address - State:OK
Mailing Address - Zip Code:74017-7022
Mailing Address - Country:US
Mailing Address - Phone:918-343-3456
Mailing Address - Fax:918-343-3456
Practice Address - Street 1:304 W WILL ROGERS BLVD
Practice Address - Street 2:
Practice Address - City:CLAREMORE
Practice Address - State:OK
Practice Address - Zip Code:74017-7022
Practice Address - Country:US
Practice Address - Phone:918-343-3456
Practice Address - Fax:918-343-3456
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-10
Last Update Date:2009-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK11751041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1175OtherSOCIAL WORK LICENSE
OK562OtherLADC LICENSE NUMBER
OK1175OtherSOCIAL WORK LICENSE
OK562OtherLADC LICENSE NUMBER