Provider Demographics
NPI:1629308028
Name:SHANKLE, KELLI
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:
Last Name:SHANKLE
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 1:205 J T STITES BLVD
Mailing Address - Street 2:
Mailing Address - City:SALLISAW
Mailing Address - State:OK
Mailing Address - Zip Code:74955-9301
Mailing Address - Country:US
Mailing Address - Phone:918-775-7787
Mailing Address - Fax:
Practice Address - Street 1:205 J T STITES BLVD
Practice Address - Street 2:
Practice Address - City:SALLISAW
Practice Address - State:OK
Practice Address - Zip Code:74955-9301
Practice Address - Country:US
Practice Address - Phone:918-775-7787
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-01-06
Last Update Date:2010-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health