Provider Demographics
NPI:1689003741
Name:LAVINE, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:LAVINE
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 1:10217 E 21ST PL
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74129-4602
Mailing Address - Country:US
Mailing Address - Phone:918-671-1934
Mailing Address - Fax:
Practice Address - Street 1:10217 E 21ST PL
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74129-4602
Practice Address - Country:US
Practice Address - Phone:918-671-1934
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-08
Last Update Date:2013-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor