Provider Demographics
NPI:1013446293
Name:ANDERSON, KAYLIE MARIE
Entity Type:Individual
Prefix:
First Name:KAYLIE
Middle Name:MARIE
Last Name:ANDERSON
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 1:3602 N WASHINGTON ST APT I85
Mailing Address - Street 2:
Mailing Address - City:STILLWATER
Mailing Address - State:OK
Mailing Address - Zip Code:74075-1327
Mailing Address - Country:US
Mailing Address - Phone:817-996-6991
Mailing Address - Fax:
Practice Address - Street 1:121 S DUCK ST
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:OK
Practice Address - Zip Code:74074-3292
Practice Address - Country:US
Practice Address - Phone:405-372-7791
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-09
Last Update Date:2017-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health