Provider Demographics
NPI:1164130563
Name:BEAN, KYLEE MARIE (PTA)
Entity Type:Individual
Prefix:
First Name:KYLEE
Middle Name:MARIE
Last Name:BEAN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:KYLEE
Other - Middle Name:MARIE
Other - Last Name:SCRAPPER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:31628 E 64TH ST S
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74014-8583
Mailing Address - Country:US
Mailing Address - Phone:918-869-7784
Mailing Address - Fax:
Practice Address - Street 1:31628 E 64TH ST S
Practice Address - Street 2:
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74014-8583
Practice Address - Country:US
Practice Address - Phone:918-869-7784
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-14
Last Update Date:2022-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3588225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant