Basic Information
| Provider Information | |||||||||
| NPI: | 1922048479 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WARD | ||||||||
| FirstName: | DUSTIN | ||||||||
| MiddleName: | GANT | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PH.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1044 SW 4TH ST | ||||||||
| Address2: | |||||||||
| City: | MOORE | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731602405 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4057356333 | ||||||||
| FaxNumber: | 4057356629 | ||||||||
| Practice Location | |||||||||
| Address1: | 1044 SW 4TH ST | ||||||||
| Address2: | |||||||||
| City: | MOORE | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731602405 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4057356333 | ||||||||
| FaxNumber: | 4057356629 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2006 | ||||||||
| LastUpdateDate: | 05/29/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC1900X | 1011 | OK | Y | Behavioral Health & Social Service Providers | Psychologist | Counseling |
ID Information
| ID | Type | State | Issuer | Description | 200075530 B | 05 | OK | MEDICAID | 200075530 C | 05 | OK | MEDICAID |