Provider Demographics
NPI:1629327358
Name:WHELAN, KELLY ROSE (LCSW)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:ROSE
Last Name:WHELAN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:616 NW 21ST ST STE 105
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73103-1861
Mailing Address - Country:US
Mailing Address - Phone:405-310-7463
Mailing Address - Fax:
Practice Address - Street 1:416 NW 23RD ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73103
Practice Address - Country:US
Practice Address - Phone:405-310-7463
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-10
Last Update Date:2022-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK50541041C0700X
PASW128966104100000X
OK4439104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200454620AMedicaid