Provider Demographics
NPI:1497059968
Name:HAMPTON, KELLYN
Entity Type:Individual
Prefix:MS
First Name:KELLYN
Middle Name:
Last Name:HAMPTON
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 1:22005 E 660 RD
Mailing Address - Street 2:
Mailing Address - City:TAHLEQUAH
Mailing Address - State:OK
Mailing Address - Zip Code:74464-8230
Mailing Address - Country:US
Mailing Address - Phone:720-402-5977
Mailing Address - Fax:
Practice Address - Street 1:711 S MUSKOGEE AVE
Practice Address - Street 2:
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74464-4717
Practice Address - Country:US
Practice Address - Phone:918-207-0078
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-12-27
Last Update Date:2021-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO10795101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health