Provider Demographics
NPI:1053657734
Name:GILLIN, MARTHA OLIVIA (BHRS)
Entity type:Individual
Prefix:
First Name:MARTHA
Middle Name:OLIVIA
Last Name:GILLIN
Suffix:
Gender:F
Credentials:BHRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2736 SW 55TH ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73119-5628
Mailing Address - Country:US
Mailing Address - Phone:405-686-9382
Mailing Address - Fax:
Practice Address - Street 1:2736 SW 55TH ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73119-5628
Practice Address - Country:US
Practice Address - Phone:405-686-9382
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-27
Last Update Date:2012-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKV081060282103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst