Basic Information
| Provider Information | |||||||||
| NPI: | 1700152238 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WEAVER | ||||||||
| FirstName: | KELLI | ||||||||
| MiddleName: | JO DAWN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | BS, BHRS | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 124 E 6TH ST | ||||||||
| Address2: | |||||||||
| City: | PAWHUSKA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 740564204 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9186046054 | ||||||||
| FaxNumber: | 9187779018 | ||||||||
| Practice Location | |||||||||
| Address1: | 124 E 6TH ST | ||||||||
| Address2: | |||||||||
| City: | PAWHUSKA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 740564204 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9186046054 | ||||||||
| FaxNumber: | 9187779018 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/29/2012 | ||||||||
| LastUpdateDate: | 06/28/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/28/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator | 103K00000X | N | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.