Healthcare Provider Details

I. General information

NPI: 1043553019
Provider Name (Legal Business Name): EDNA C KELLY LPC - CANDIDATE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/28/2013
Last Update Date: 09/27/2026
Certification Date: 09/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 NW 5TH ST STE D
MOORE OK
73160-3947
US

IV. Provider business mailing address

733 NE 20TH ST
MOORE OK
73160-5649
US

V. Phone/Fax

Practice location:
  • Phone: 405-208-4469
  • Fax: 405-208-4472
Mailing address:
  • Phone: 405-708-3422
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberLPCCANDIDATE13677
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: