Provider Demographics
NPI:1275771735
Name:ELLIOTT, KENNETH WAYNE (LMFT)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:WAYNE
Last Name:ELLIOTT
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1308 COPPERFIELD DR
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73003-6101
Mailing Address - Country:US
Mailing Address - Phone:405-715-0216
Mailing Address - Fax:
Practice Address - Street 1:1308 COPPERFIELD DR
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73003-6101
Practice Address - Country:US
Practice Address - Phone:405-715-0216
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-21
Last Update Date:2009-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK763106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100742400BMedicaid