Provider Demographics
NPI:1245522515
Name:GLOVER, KIMELLA DENISE
Entity type:Individual
Prefix:
First Name:KIMELLA
Middle Name:DENISE
Last Name:GLOVER
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 1:1215 NE 59TH ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73111-7403
Mailing Address - Country:US
Mailing Address - Phone:405-630-4329
Mailing Address - Fax:
Practice Address - Street 1:1215 NE 59TH ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73111-7403
Practice Address - Country:US
Practice Address - Phone:405-630-4329
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-05
Last Update Date:2011-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200123000AMedicaid