Provider Demographics
NPI:1003856741
Name:GRIFFITH, KELLY J (PHD)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:J
Last Name:GRIFFITH
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1024 W LAKERIDGE AVE
Mailing Address - Street 2:
Mailing Address - City:STILLWATER
Mailing Address - State:OK
Mailing Address - Zip Code:74075-2106
Mailing Address - Country:US
Mailing Address - Phone:405-612-8292
Mailing Address - Fax:
Practice Address - Street 1:1024 W LAKERIDGE AVE
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:OK
Practice Address - Zip Code:74075-2106
Practice Address - Country:US
Practice Address - Phone:405-612-8292
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK792103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent