Provider Demographics
NPI:1700435450
Name:GONZALES, MISTY DAWN
Entity Type:Individual
Prefix:
First Name:MISTY
Middle Name:DAWN
Last Name:GONZALES
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 1:4200 SE ADAMS RD
Mailing Address - Street 2:
Mailing Address - City:BARTLESVILLE
Mailing Address - State:OK
Mailing Address - Zip Code:74006-8448
Mailing Address - Country:US
Mailing Address - Phone:918-331-9050
Mailing Address - Fax:
Practice Address - Street 1:4200 SE ADAMS RD
Practice Address - Street 2:
Practice Address - City:BARTLESVILLE
Practice Address - State:OK
Practice Address - Zip Code:74006-8448
Practice Address - Country:US
Practice Address - Phone:918-331-9050
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-05
Last Update Date:2019-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1003365867OtherGROUP NPI