Provider Demographics
NPI:1023214038
Name:PETERSON, GAY LYNN
Entity type:Individual
Prefix:MISS
First Name:GAY
Middle Name:LYNN
Last Name:PETERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1116 S FLORIDA AVE
Mailing Address - Street 2:
Mailing Address - City:OKMULGEE
Mailing Address - State:OK
Mailing Address - Zip Code:74447-6200
Mailing Address - Country:US
Mailing Address - Phone:918-756-4512
Mailing Address - Fax:
Practice Address - Street 1:323 W 6TH ST
Practice Address - Street 2:
Practice Address - City:OKMULGEE
Practice Address - State:OK
Practice Address - Zip Code:74447-5019
Practice Address - Country:US
Practice Address - Phone:918-756-9250
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-26
Last Update Date:2009-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK300522336OtherMEDICARE