Provider Demographics
NPI:1679964498
Name:ALLEN, KELLY R (LADC/MH)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:R
Last Name:ALLEN
Suffix:
Gender:F
Credentials:LADC/MH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:77 CARDINAL DR
Mailing Address - Street 2:
Mailing Address - City:MEAD
Mailing Address - State:OK
Mailing Address - Zip Code:73449-6550
Mailing Address - Country:US
Mailing Address - Phone:903-327-9410
Mailing Address - Fax:
Practice Address - Street 1:622 BRYAN DR
Practice Address - Street 2:
Practice Address - City:DURANT
Practice Address - State:OK
Practice Address - Zip Code:74701-3462
Practice Address - Country:US
Practice Address - Phone:903-327-9410
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-16
Last Update Date:2024-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4608101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)