Provider Demographics
NPI:1144535758
Name:GILMORE, TINA RENEE (MS)
Entity type:Individual
Prefix:MRS
First Name:TINA
Middle Name:RENEE
Last Name:GILMORE
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:704 N OAK AVE STE 20
Mailing Address - Street 2:
Mailing Address - City:ADA
Mailing Address - State:OK
Mailing Address - Zip Code:74820-3267
Mailing Address - Country:US
Mailing Address - Phone:580-332-3001
Mailing Address - Fax:580-332-3652
Practice Address - Street 1:704 N OAK AVE STE 20
Practice Address - Street 2:
Practice Address - City:ADA
Practice Address - State:OK
Practice Address - Zip Code:74820-3267
Practice Address - Country:US
Practice Address - Phone:580-332-3001
Practice Address - Fax:580-332-3652
Is Sole Proprietor?:No
Enumeration Date:2010-08-09
Last Update Date:2010-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100732530AMedicaid