Provider Demographics
NPI:1235531245
Name:KOONCE, KAYXANDRA
Entity Type:Individual
Prefix:
First Name:KAYXANDRA
Middle Name:
Last Name:KOONCE
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 1:33101 HARDESTY RD
Mailing Address - Street 2:
Mailing Address - City:SHAWNEE
Mailing Address - State:OK
Mailing Address - Zip Code:74801-5677
Mailing Address - Country:US
Mailing Address - Phone:405-338-8187
Mailing Address - Fax:
Practice Address - Street 1:101 N UNION AVE
Practice Address - Street 2:
Practice Address - City:SHAWNEE
Practice Address - State:OK
Practice Address - Zip Code:74801-7067
Practice Address - Country:US
Practice Address - Phone:405-275-7100
Practice Address - Fax:405-275-7105
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-22
Last Update Date:2014-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKG083213750104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker