Provider Demographics
NPI:1831438290
Name:MCKELLY, MICHELLE (BHRS)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:MCKELLY
Suffix:
Gender:F
Credentials:BHRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:351 N AIR DEPOT BLVD
Mailing Address - Street 2:SUITE M
Mailing Address - City:MIDWEST CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73110-1700
Mailing Address - Country:US
Mailing Address - Phone:405-269-5678
Mailing Address - Fax:
Practice Address - Street 1:351 N AIR DEPOT BLVD
Practice Address - Street 2:SUITE M
Practice Address - City:MIDWEST CITY
Practice Address - State:OK
Practice Address - Zip Code:73110-1700
Practice Address - Country:US
Practice Address - Phone:405-269-5678
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-05
Last Update Date:2013-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor