Provider Demographics
NPI:1508160219
Name:WHITE, KELLY ANN (LCSW)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:ANN
Last Name:WHITE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15222 SUNSET WAY
Mailing Address - Street 2:
Mailing Address - City:CHOCTAW
Mailing Address - State:OK
Mailing Address - Zip Code:73020-7565
Mailing Address - Country:US
Mailing Address - Phone:405-640-4574
Mailing Address - Fax:405-390-1820
Practice Address - Street 1:15222 SUNSET WAY
Practice Address - Street 2:
Practice Address - City:CHOCTAW
Practice Address - State:OK
Practice Address - Zip Code:73020-7565
Practice Address - Country:US
Practice Address - Phone:405-640-4574
Practice Address - Fax:405-390-1820
Is Sole Proprietor?:No
Enumeration Date:2011-01-10
Last Update Date:2011-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK29671041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical