Provider Demographics
NPI:1669528733
Name:GARDNER- RUMINER, LISA DEE (MED)
Entity type:Individual
Prefix:MS
First Name:LISA
Middle Name:DEE
Last Name:GARDNER- RUMINER
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4436 NW 50TH ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73112-2212
Mailing Address - Country:US
Mailing Address - Phone:405-272-0660
Mailing Address - Fax:
Practice Address - Street 1:711 STANTON L YOUNG BLVD STE 430
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73104-5022
Practice Address - Country:US
Practice Address - Phone:405-271-6434
Practice Address - Fax:405-271-6264
Is Sole Proprietor?:No
Enumeration Date:2007-01-25
Last Update Date:2020-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2492101YM0800X, 103G00000X
101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist