Provider Demographics
NPI:1609464650
Name:MIGNANO, KELSEY ELIZABETH (RBT)
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:ELIZABETH
Last Name:MIGNANO
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1320 12TH AVE SE
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73071-2560
Mailing Address - Country:US
Mailing Address - Phone:724-814-6219
Mailing Address - Fax:
Practice Address - Street 1:13905 TECHNOLOGY DR
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73134-1054
Practice Address - Country:US
Practice Address - Phone:724-814-6219
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-05
Last Update Date:2021-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician