Provider Demographics
NPI:1093489775
Name:KETTLEWOOD, ANNA MARIA (LCSW)
Entity Type:Individual
Prefix:
First Name:ANNA
Middle Name:MARIA
Last Name:KETTLEWOOD
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5319 S LEWIS AVE STE 219
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74105-6543
Mailing Address - Country:US
Mailing Address - Phone:918-832-7763
Mailing Address - Fax:
Practice Address - Street 1:604 S WALNUT ST
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:OK
Practice Address - Zip Code:74074-4222
Practice Address - Country:US
Practice Address - Phone:539-240-0911
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-05
Last Update Date:2023-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
OK20535101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)