Provider Demographics
NPI:1205265238
Name:RAINWATER, KELLY
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:RAINWATER
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:PO BOX 1022
Mailing Address - Street 2:
Mailing Address - City:TALIHINA
Mailing Address - State:OK
Mailing Address - Zip Code:74571-1022
Mailing Address - Country:US
Mailing Address - Phone:918-413-5600
Mailing Address - Fax:918-567-2382
Practice Address - Street 1:53900 442ND AVENUE
Practice Address - Street 2:
Practice Address - City:TALIHINA
Practice Address - State:OK
Practice Address - Zip Code:74571-1022
Practice Address - Country:US
Practice Address - Phone:918-413-5600
Practice Address - Fax:918-567-2382
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-12
Last Update Date:2013-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitation