Provider Demographics
NPI:1528400298
Name:WHITEHEAD, KELLY (MOT)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:WHITEHEAD
Suffix:
Gender:F
Credentials:MOT
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:NEAL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MOT
Mailing Address - Street 1:6800 NW 39TH EXPY
Mailing Address - Street 2:
Mailing Address - City:BETHANY
Mailing Address - State:OK
Mailing Address - Zip Code:73008-2513
Mailing Address - Country:US
Mailing Address - Phone:405-789-6711
Mailing Address - Fax:
Practice Address - Street 1:6800 NW 39TH EXPY
Practice Address - Street 2:
Practice Address - City:BETHANY
Practice Address - State:OK
Practice Address - Zip Code:73008-2513
Practice Address - Country:US
Practice Address - Phone:405-789-6711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-23
Last Update Date:2015-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200499510Medicaid