Provider Demographics
NPI:1134287378
Name:BIRDSONG, KIM LEIGH (LPC)
Entity Type:Individual
Prefix:MRS
First Name:KIM
Middle Name:LEIGH
Last Name:BIRDSONG
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:MS
Other - First Name:KIM
Other - Middle Name:LEIGH
Other - Last Name:MARTIN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LPC
Mailing Address - Street 1:2117 BAINBRIDGE AVE
Mailing Address - Street 2:
Mailing Address - City:PONCA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:74604-2404
Mailing Address - Country:US
Mailing Address - Phone:580-762-4374
Mailing Address - Fax:
Practice Address - Street 1:1500 N 6TH ST
Practice Address - Street 2:
Practice Address - City:PONCA CITY
Practice Address - State:OK
Practice Address - Zip Code:74601-2827
Practice Address - Country:US
Practice Address - Phone:580-762-7561
Practice Address - Fax:580-762-2576
Is Sole Proprietor?:No
Enumeration Date:2006-12-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3112101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor