Provider Demographics
NPI:1730524802
Name:KELLY, MISTYE
Entity type:Individual
Prefix:
First Name:MISTYE
Middle Name:
Last Name:KELLY
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 1:716 SW 1ST ST
Mailing Address - Street 2:
Mailing Address - City:MOORE
Mailing Address - State:OK
Mailing Address - Zip Code:73160-2301
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:716 SW 1ST ST
Practice Address - Street 2:
Practice Address - City:MOORE
Practice Address - State:OK
Practice Address - Zip Code:73160-2301
Practice Address - Country:US
Practice Address - Phone:405-735-7786
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-02
Last Update Date:2016-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health