Provider Demographics
NPI:1477288942
Name:DORSE, KAYETLYN NICOLE
Entity Type:Individual
Prefix:
First Name:KAYETLYN
Middle Name:NICOLE
Last Name:DORSE
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 1:2717 MEADOW WOOD PL UNIT B
Mailing Address - Street 2:
Mailing Address - City:CLAREMORE
Mailing Address - State:OK
Mailing Address - Zip Code:74017-4868
Mailing Address - Country:US
Mailing Address - Phone:918-616-4757
Mailing Address - Fax:
Practice Address - Street 1:1516 S BOSTON AVE STE 1
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74119-4029
Practice Address - Country:US
Practice Address - Phone:918-561-6000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-19
Last Update Date:2022-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker