Provider Demographics
NPI:1891940045
Name:WHITEWOLF, GORDON RAY (LBP)
Entity Type:Individual
Prefix:MR
First Name:GORDON
Middle Name:RAY
Last Name:WHITEWOLF
Suffix:
Gender:M
Credentials:LBP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101RIVERSIDE DRIVE
Mailing Address - Street 2:
Mailing Address - City:ANADARKO
Mailing Address - State:OK
Mailing Address - Zip Code:73005
Mailing Address - Country:US
Mailing Address - Phone:405-247-6670
Mailing Address - Fax:405-247-2029
Practice Address - Street 1:101 RIVERSIDE DRIVE
Practice Address - Street 2:RIVERSIDE INDIAN SCHOOL
Practice Address - City:ANADARKO
Practice Address - State:OK
Practice Address - Zip Code:73005
Practice Address - Country:US
Practice Address - Phone:405-247-6670
Practice Address - Fax:405-247-2029
Is Sole Proprietor?:No
Enumeration Date:2008-12-01
Last Update Date:2008-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK386101YA0400X
OK0216101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)