Provider Demographics
NPI:1740581586
Name:STANDINGWATER, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:STANDINGWATER
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 1:3100 S ELM PL STE B
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74012-7950
Mailing Address - Country:US
Mailing Address - Phone:918-286-2535
Mailing Address - Fax:918-286-7693
Practice Address - Street 1:3100 S ELM PL STE B
Practice Address - Street 2:
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74012-7950
Practice Address - Country:US
Practice Address - Phone:918-286-2535
Practice Address - Fax:918-286-7693
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-10
Last Update Date:2010-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor