Healthcare Provider Details

I. General information

NPI: 1356229181
Provider Name (Legal Business Name): KILDARE PUBLIC SCHOOL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/21/2025
Last Update Date: 08/21/2025
Certification Date: 08/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1265 CHURCH ST
PONCA CITY OK
74604-7019
US

IV. Provider business mailing address

1265 CHURCH ST
PONCA CITY OK
74604-7019
US

V. Phone/Fax

Practice location:
  • Phone: 580-362-2811
  • Fax:
Mailing address:
  • Phone: 580-362-2811
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

Name: BRUCE SHELLEY
Title or Position: SUPERINTENDENT
Credential:
Phone: 580-761-7440