Provider Demographics
NPI:1013327022
Name:KELLEY, EPHRAIM
Entity Type:Individual
Prefix:
First Name:EPHRAIM
Middle Name:
Last Name:KELLEY
Suffix:
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 1:2800 N. ROCKWELL AVE.
Mailing Address - Street 2:
Mailing Address - City:BETHANY
Mailing Address - State:OK
Mailing Address - Zip Code:73008
Mailing Address - Country:US
Mailing Address - Phone:405-933-4581
Mailing Address - Fax:
Practice Address - Street 1:2800 N. ROCKWELL AVE.
Practice Address - Street 2:
Practice Address - City:BETHANY
Practice Address - State:OK
Practice Address - Zip Code:73008
Practice Address - Country:US
Practice Address - Phone:405-933-4581
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-29
Last Update Date:2014-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKC081932107101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor