Provider Demographics
NPI:1922048479
Name:WARD, DUSTIN GANT (PHD)
Entity Type:Individual
Prefix:DR
First Name:DUSTIN
Middle Name:GANT
Last Name:WARD
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1044 SW 4TH ST
Mailing Address - Street 2:
Mailing Address - City:MOORE
Mailing Address - State:OK
Mailing Address - Zip Code:73160-2405
Mailing Address - Country:US
Mailing Address - Phone:405-735-6333
Mailing Address - Fax:405-735-6629
Practice Address - Street 1:1044 SW 4TH ST
Practice Address - Street 2:
Practice Address - City:MOORE
Practice Address - State:OK
Practice Address - Zip Code:73160-2405
Practice Address - Country:US
Practice Address - Phone:405-735-6333
Practice Address - Fax:405-735-6629
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2015-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1011103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200075530 BMedicaid
OK200075530 CMedicaid
OK200075530 CMedicaid