Provider Demographics
NPI:1518218007
Name:BLANKENSHIP, KELLIE
Entity Type:Individual
Prefix:
First Name:KELLIE
Middle Name:
Last Name:BLANKENSHIP
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 1:1805 N YORK ST
Mailing Address - Street 2:SUITE G
Mailing Address - City:MUSKOGEE
Mailing Address - State:OK
Mailing Address - Zip Code:74403-1404
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1805 N YORK ST
Practice Address - Street 2:SUITE G
Practice Address - City:MUSKOGEE
Practice Address - State:OK
Practice Address - Zip Code:74403-1404
Practice Address - Country:US
Practice Address - Phone:918-682-9292
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-25
Last Update Date:2012-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health