Provider Demographics
NPI:1396980728
Name:FLACK, GAIL MARY (LCSW)
Entity type:Individual
Prefix:MS
First Name:GAIL
Middle Name:MARY
Last Name:FLACK
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2507 E 2ND ST
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74104-1903
Mailing Address - Country:US
Mailing Address - Phone:918-584-0290
Mailing Address - Fax:918-584-0290
Practice Address - Street 1:635 W 11TH ST
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74127-9014
Practice Address - Country:US
Practice Address - Phone:918-382-3541
Practice Address - Fax:918-382-4621
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-15
Last Update Date:2008-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3550261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty