Provider Demographics
NPI:1487930400
Name:KELLY, AUDREY J (LMFT)
Entity type:Individual
Prefix:
First Name:AUDREY
Middle Name:J
Last Name:KELLY
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:RT 2 BOX 1292
Mailing Address - Street 2:
Mailing Address - City:CHECOTAH
Mailing Address - State:OK
Mailing Address - Zip Code:74426
Mailing Address - Country:US
Mailing Address - Phone:405-640-4726
Mailing Address - Fax:
Practice Address - Street 1:RT 2
Practice Address - Street 2:
Practice Address - City:CHECOTAH
Practice Address - State:OK
Practice Address - Zip Code:74426
Practice Address - Country:US
Practice Address - Phone:405-640-4726
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-24
Last Update Date:2011-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1026106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist