Provider Demographics
NPI:1881842870
Name:PETTY, KIMBERLY S (MS)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:S
Last Name:PETTY
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10310 N 138TH EAST AVE STE 201
Mailing Address - Street 2:
Mailing Address - City:OWASSO
Mailing Address - State:OK
Mailing Address - Zip Code:74055-4641
Mailing Address - Country:US
Mailing Address - Phone:918-520-1202
Mailing Address - Fax:918-340-6383
Practice Address - Street 1:10310 N 138TH EAST AVE STE 201
Practice Address - Street 2:
Practice Address - City:OWASSO
Practice Address - State:OK
Practice Address - Zip Code:74055-4641
Practice Address - Country:US
Practice Address - Phone:918-520-1202
Practice Address - Fax:918-340-6383
Is Sole Proprietor?:No
Enumeration Date:2008-09-03
Last Update Date:2023-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1881842870Medicaid