Provider Demographics
NPI:1720234172
Name:TUBBS, KELLEY EDWARD (LMSW)
Entity Type:Individual
Prefix:MR
First Name:KELLEY
Middle Name:EDWARD
Last Name:TUBBS
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4436 NW 50TH ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73112-2212
Mailing Address - Country:US
Mailing Address - Phone:405-810-9578
Mailing Address - Fax:
Practice Address - Street 1:2512 S HARVEY AVE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73109-5958
Practice Address - Country:US
Practice Address - Phone:405-810-9578
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-15
Last Update Date:2008-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS7179104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker