Provider Demographics
NPI:1073936803
Name:LINGO, KELLY A
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:A
Last Name:LINGO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:KINGFISHER
Mailing Address - State:OK
Mailing Address - Zip Code:73750-2720
Mailing Address - Country:US
Mailing Address - Phone:405-375-3735
Mailing Address - Fax:405-262-1331
Practice Address - Street 1:107 N MAIN ST
Practice Address - Street 2:
Practice Address - City:KINGFISHER
Practice Address - State:OK
Practice Address - Zip Code:73750-2720
Practice Address - Country:US
Practice Address - Phone:405-375-3735
Practice Address - Fax:405-262-1331
Is Sole Proprietor?:No
Enumeration Date:2014-01-30
Last Update Date:2014-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health