Basic Information
| Provider Information | |||||||||
| NPI: | 1083930044 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GBODI | ||||||||
| FirstName: | PAUL | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | LPC CANDIDATE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11604 WALLACE AVE | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731621356 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4057063131 | ||||||||
| FaxNumber: | 4057217705 | ||||||||
| Practice Location | |||||||||
| Address1: | 2220 N CLASSEN BLVD | ||||||||
| Address2: | SUITE E | ||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731065809 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4055281748 | ||||||||
| FaxNumber: | 4055281802 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/15/2010 | ||||||||
| LastUpdateDate: | 04/15/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | OK | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 200120060A | 05 | OK | MEDICAID |