Provider Demographics
NPI:1770911612
Name:OLDFATHER, GAYLA (LMSW)
Entity type:Individual
Prefix:
First Name:GAYLA
Middle Name:
Last Name:OLDFATHER
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2809 FOREST HOME RD
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72401-5320
Mailing Address - Country:US
Mailing Address - Phone:866-972-1268
Mailing Address - Fax:
Practice Address - Street 1:1820 CENTRAL AVE STE B
Practice Address - Street 2:
Practice Address - City:HOT SPRINGS
Practice Address - State:AR
Practice Address - Zip Code:71901-6898
Practice Address - Country:US
Practice Address - Phone:501-623-6000
Practice Address - Fax:501-623-6004
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-30
Last Update Date:2022-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS8961104100000X
AR8723-M104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker