Healthcare Provider Details

I. General information

NPI: 1659582435
Provider Name (Legal Business Name): KENNETH LEE WHEELER MDIV
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/24/2007
Last Update Date: 08/10/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2303 S YORK ST
MUSKOGEE OK
74403-8876
US

IV. Provider business mailing address

427 S 13TH ST
MUSKOGEE OK
74401-7102
US

V. Phone/Fax

Practice location:
  • Phone: 918-686-5588
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberUNDER SUPERVISION
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: