Provider Demographics
NPI:1770979478
Name:ELLER, KELSEY
Entity type:Individual
Prefix:
First Name:KELSEY
Middle Name:
Last Name:ELLER
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 1:4943 ULAN RD
Mailing Address - Street 2:
Mailing Address - City:INDIANOLA
Mailing Address - State:OK
Mailing Address - Zip Code:74442-5019
Mailing Address - Country:US
Mailing Address - Phone:918-429-8507
Mailing Address - Fax:
Practice Address - Street 1:512 E CHICKASAW AVE
Practice Address - Street 2:
Practice Address - City:MCALESTER
Practice Address - State:OK
Practice Address - Zip Code:74501-5354
Practice Address - Country:US
Practice Address - Phone:918-302-0389
Practice Address - Fax:918-302-3809
Is Sole Proprietor?:No
Enumeration Date:2015-04-09
Last Update Date:2015-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health