Provider Demographics
NPI:1427212281
Name:HORTON, KATHLEEN MARIE
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:MARIE
Last Name:HORTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KATHLEEN
Other - Middle Name:MARIE
Other - Last Name:HORTON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPC
Mailing Address - Street 1:PO BOX 295
Mailing Address - Street 2:
Mailing Address - City:BOLEY
Mailing Address - State:OK
Mailing Address - Zip Code:74829-0295
Mailing Address - Country:US
Mailing Address - Phone:918-667-9967
Mailing Address - Fax:918-667-3387
Practice Address - Street 1:ROUTE 1 BOX 35 D
Practice Address - Street 2:
Practice Address - City:BOLEY
Practice Address - State:OK
Practice Address - Zip Code:74829-0295
Practice Address - Country:US
Practice Address - Phone:918-667-9967
Practice Address - Fax:918-667-3387
Is Sole Proprietor?:No
Enumeration Date:2008-07-10
Last Update Date:2012-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3598101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100734620DMedicaid