Basic Information
| Provider Information | |||||||||
| NPI: | 1730311291 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KINKADE | ||||||||
| FirstName: | VIRGINIA | ||||||||
| MiddleName: | PEMBERTON PATTON | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 210 E MAIN ST | ||||||||
| Address2: | RESOURCE MANAGEMENT | ||||||||
| City: | ADA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 74820 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5804367211 | ||||||||
| FaxNumber: | 5802725757 | ||||||||
| Practice Location | |||||||||
| Address1: | 124 E MAIN ST SUITE 2 | ||||||||
| Address2: | THE CHICKASAW NATION DEPT OF FAMILY SERVICES | ||||||||
| City: | ADA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 74820 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5803107993 | ||||||||
| FaxNumber: | 4058784708 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/18/2009 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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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 | 104100000X | OK | N | Behavioral Health & Social Service Providers | Social Worker | 1041C0700X | 4854 | OK | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.