Provider Demographics
NPI:1841557881
Name:GADDIS, KENTRELL L SR
Entity Type:Individual
Prefix:
First Name:KENTRELL
Middle Name:L
Last Name:GADDIS
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4026 NE 19TH CIR
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73121-4604
Mailing Address - Country:US
Mailing Address - Phone:405-589-9260
Mailing Address - Fax:
Practice Address - Street 1:4026 NE 19TH CIRCLE
Practice Address - Street 2:
Practice Address - City:OKC
Practice Address - State:OK
Practice Address - Zip Code:73121-4604
Practice Address - Country:US
Practice Address - Phone:405-589-9260
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-16
Last Update Date:2012-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKM999910701103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst