Provider Demographics
NPI:1982107645
Name:KIPPS, KAITLYN MARIE
Entity Type:Individual
Prefix:
First Name:KAITLYN
Middle Name:MARIE
Last Name:KIPPS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KAITLYN
Other - Middle Name:MARIE
Other - Last Name:GOODSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:609 E WRANGLER BLVD
Mailing Address - Street 2:
Mailing Address - City:SEMINOLE
Mailing Address - State:OK
Mailing Address - Zip Code:74868-2640
Mailing Address - Country:US
Mailing Address - Phone:405-380-5033
Mailing Address - Fax:
Practice Address - Street 1:609 E WRANGLER BLVD
Practice Address - Street 2:
Practice Address - City:SEMINOLE
Practice Address - State:OK
Practice Address - Zip Code:74868-2640
Practice Address - Country:US
Practice Address - Phone:405-380-5033
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-08
Last Update Date:2023-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK171M00000X
101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No171M00000XOther Service ProvidersCase Manager/Care Coordinator