Provider Demographics
NPI:1396437851
Name:KITTELSON, MALLORY ANNE
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:ANNE
Last Name:KITTELSON
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 1:1537 TELLURIDE LN
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73071-7438
Mailing Address - Country:US
Mailing Address - Phone:920-453-8271
Mailing Address - Fax:
Practice Address - Street 1:2405 PALMER CIR STE 100
Practice Address - Street 2:
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73069-6351
Practice Address - Country:US
Practice Address - Phone:405-561-7928
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-23
Last Update Date:2024-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician