Provider Demographics
NPI:1003171711
Name:COLLINS, KELLY MICHELLE (PH D, LPC NCC RPT)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:MICHELLE
Last Name:COLLINS
Suffix:
Gender:F
Credentials:PH D, LPC NCC RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:623 N CAROLYN DR
Mailing Address - Street 2:
Mailing Address - City:CHOCTAW
Mailing Address - State:OK
Mailing Address - Zip Code:73020-7481
Mailing Address - Country:US
Mailing Address - Phone:405-464-8679
Mailing Address - Fax:
Practice Address - Street 1:15803 NE 23RD ST # B
Practice Address - Street 2:
Practice Address - City:CHOCTAW
Practice Address - State:OK
Practice Address - Zip Code:73020-8428
Practice Address - Country:US
Practice Address - Phone:405-639-9999
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-09
Last Update Date:2013-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2381101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional