Provider Demographics
NPI:1649548413
Name:STEGALL, KIMBERLY
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:STEGALL
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 892
Mailing Address - Street 2:
Mailing Address - City:TALIHINA
Mailing Address - State:OK
Mailing Address - Zip Code:74571-0892
Mailing Address - Country:US
Mailing Address - Phone:918-413-1148
Mailing Address - Fax:
Practice Address - Street 1:501 VETERANS STREET
Practice Address - Street 2:V
Practice Address - City:TALIHINA
Practice Address - State:OK
Practice Address - Zip Code:74571
Practice Address - Country:US
Practice Address - Phone:918-413-1148
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-08
Last Update Date:2011-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health