Basic Information
| Provider Information | |||||||||
| NPI: | 1396258562 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | KELLIE | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BAILEY | ||||||||
| OtherFirstName: | KELLIE | ||||||||
| OtherMiddleName: | ANN | ||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 11006 S JAMES CT | ||||||||
| Address2: | |||||||||
| City: | JENKS | ||||||||
| State: | OK | ||||||||
| PostalCode: | 740371663 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9189490960 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 7010 S YALE AVE STE 215 | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741365743 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9184922554 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/10/2017 | ||||||||
| LastUpdateDate: | 11/10/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.