Basic Information
| Provider Information | |||||||||
| NPI: | 1013245364 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GAINES | ||||||||
| FirstName: | MICHELLE | ||||||||
| MiddleName: | LEE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MA, LBP, CCRC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 2801 PARKLAWN DR STE 303 | ||||||||
| Address2: | |||||||||
| City: | MIDWEST CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731104230 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4052459233 | ||||||||
| FaxNumber: | 4056103647 | ||||||||
| Practice Location | |||||||||
| Address1: | 2801 PARKLAWN DR STE 303 | ||||||||
| Address2: | |||||||||
| City: | MIDWEST CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731104230 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4056103644 | ||||||||
| FaxNumber: | 4056103647 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/25/2009 | ||||||||
| LastUpdateDate: | 12/30/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/30/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 0089 | OK | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YP2500X | 0089 | OK | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 200330740B | 05 | OK | MEDICAID |