Healthcare Provider Details

I. General information

NPI: 1588583710
Provider Name (Legal Business Name): MICHAEL SHAWN KENNEDY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/13/2026
Last Update Date: 07/13/2026
Certification Date: 07/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

113262 S 4620 RD
SALLISAW OK
74955-7991
US

IV. Provider business mailing address

113262 S 4620 RD
SALLISAW OK
74955-7991
US

V. Phone/Fax

Practice location:
  • Phone: 918-315-0315
  • Fax:
Mailing address:
  • Phone: 918-315-0315
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: