Provider Demographics
NPI:1790159382
Name:KELLEY, CARISSA NICOLE
Entity Type:Individual
Prefix:MRS
First Name:CARISSA
Middle Name:NICOLE
Last Name:KELLEY
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 1:2215 W WRANGLER BLVD APT 135
Mailing Address - Street 2:
Mailing Address - City:SEMINOLE
Mailing Address - State:OK
Mailing Address - Zip Code:74868-2098
Mailing Address - Country:US
Mailing Address - Phone:405-584-1350
Mailing Address - Fax:
Practice Address - Street 1:2215 W. WRANGLER BLVD. APT. 135
Practice Address - Street 2:
Practice Address - City:SEMINOLE
Practice Address - State:OK
Practice Address - Zip Code:74868
Practice Address - Country:US
Practice Address - Phone:405-584-1350
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-19
Last Update Date:2015-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)