Healthcare Provider Details

I. General information

NPI: 1588990022
Provider Name (Legal Business Name): KELLI J NOWLIN LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KELLI DEERINWATER LPC

II. Dates (important events)

Enumeration Date: 10/18/2009
Last Update Date: 04/20/2020
Certification Date: 04/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1088 S GIN RD
ATOKA OK
74525-7378
US

IV. Provider business mailing address

1088 S GIN RD
ATOKA OK
74525-7378
US

V. Phone/Fax

Practice location:
  • Phone: 580-239-2071
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number4550
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number4550
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: