Provider Demographics
NPI:1215593876
Name:MOON, KELBIE (MS)
Entity Type:Individual
Prefix:
First Name:KELBIE
Middle Name:
Last Name:MOON
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 902
Mailing Address - Street 2:
Mailing Address - City:WILBURTON
Mailing Address - State:OK
Mailing Address - Zip Code:74578-0902
Mailing Address - Country:US
Mailing Address - Phone:800-275-8777
Mailing Address - Fax:
Practice Address - Street 1:1029 E WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:MCALESTER
Practice Address - State:OK
Practice Address - Zip Code:74501-4849
Practice Address - Country:US
Practice Address - Phone:918-423-2220
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-18
Last Update Date:2019-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKCF102235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist