Provider Demographics
NPI:1730460478
Name:KIBBLEWHITE, LISA JOY (MSW)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:JOY
Last Name:KIBBLEWHITE
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3301 NW 21ST ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73107-3013
Mailing Address - Country:US
Mailing Address - Phone:405-550-9789
Mailing Address - Fax:
Practice Address - Street 1:3301 NW 21ST ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73107-3013
Practice Address - Country:US
Practice Address - Phone:405-550-9789
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-08
Last Update Date:2013-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKE082497603Medicaid