Provider Demographics
NPI:1376969063
Name:KIELKOPF, DEREK
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:
Last Name:KIELKOPF
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3412 ARCADIA DR
Mailing Address - Street 2:
Mailing Address - City:YUKON
Mailing Address - State:OK
Mailing Address - Zip Code:73099-9643
Mailing Address - Country:US
Mailing Address - Phone:920-645-3939
Mailing Address - Fax:
Practice Address - Street 1:400 N BROADWAY ST
Practice Address - Street 2:
Practice Address - City:MOORE
Practice Address - State:OK
Practice Address - Zip Code:73160-4812
Practice Address - Country:US
Practice Address - Phone:405-735-4650
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-05
Last Update Date:2014-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health