Provider Demographics
NPI:1366554099
Name:GODFREY, KELLY B (OTR/L)
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:B
Last Name:GODFREY
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5110 S YALE AVE
Mailing Address - Street 2:STE 103
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74135-7401
Mailing Address - Country:US
Mailing Address - Phone:918-492-2386
Mailing Address - Fax:918-645-8686
Practice Address - Street 1:5110 S YALE AVE
Practice Address - Street 2:STE 103
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74135-7401
Practice Address - Country:US
Practice Address - Phone:918-492-2386
Practice Address - Fax:918-645-8686
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2012-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1464225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200085750AMedicaid