Provider Demographics
NPI:1679393904
Name:GARRISON, NICOLE M
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:M
Last Name:GARRISON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:M
Other - Last Name:GILL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1712 S POST RD STE A
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73130-6614
Mailing Address - Country:US
Mailing Address - Phone:405-394-4831
Mailing Address - Fax:405-610-5259
Practice Address - Street 1:1712 S POST RD STE A
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73130-6614
Practice Address - Country:US
Practice Address - Phone:405-394-4831
Practice Address - Fax:405-610-5259
Is Sole Proprietor?:No
Enumeration Date:2024-10-11
Last Update Date:2024-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKRBT-24-384864106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician