Provider Demographics
NPI:1992200760
Name:GUEST, WILLIE GENE JR
Entity Type:Individual
Prefix:
First Name:WILLIE
Middle Name:GENE
Last Name:GUEST
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:431 W CHANTILLY WAY
Mailing Address - Street 2:
Mailing Address - City:MUSTANG
Mailing Address - State:OK
Mailing Address - Zip Code:73064-3929
Mailing Address - Country:US
Mailing Address - Phone:405-833-7639
Mailing Address - Fax:
Practice Address - Street 1:431 W CHANTILLY WAY
Practice Address - Street 2:
Practice Address - City:MUSTANG
Practice Address - State:OK
Practice Address - Zip Code:73064-3929
Practice Address - Country:US
Practice Address - Phone:405-833-7639
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-26
Last Update Date:2021-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK7850104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker