Provider Demographics
NPI:1528385408
Name:DUE, KELLY RAE (CADC)
Entity Type:Individual
Prefix:MS
First Name:KELLY
Middle Name:RAE
Last Name:DUE
Suffix:
Gender:F
Credentials:CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6355 S 80TH EAST AVE APT K
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74133-3813
Mailing Address - Country:US
Mailing Address - Phone:918-902-1170
Mailing Address - Fax:
Practice Address - Street 1:6355 S 80TH EAST AVE APT K
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74133-3813
Practice Address - Country:US
Practice Address - Phone:918-902-1170
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-30
Last Update Date:2010-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK14397101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK14397OtherOKLAHOMA CADC