Provider Demographics
NPI:1255173431
Name:VANDIVER, KALEY SUE
Entity type:Individual
Prefix:
First Name:KALEY
Middle Name:SUE
Last Name:VANDIVER
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 1:1019 WATERWOOD PKWY STE B
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73034-5329
Mailing Address - Country:US
Mailing Address - Phone:405-648-8978
Mailing Address - Fax:
Practice Address - Street 1:1019 WATERWOOD PKWY STE B
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73034-5329
Practice Address - Country:US
Practice Address - Phone:405-648-8978
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-10
Last Update Date:2024-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK11181101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional