Healthcare Provider Details

I. General information

NPI: 1285042002
Provider Name (Legal Business Name): KEN D BOND JR. PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: KEN D BOND PH.D.

II. Dates (important events)

Enumeration Date: 07/24/2014
Last Update Date: 12/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1127 N KICKAPOO AVE
SHAWNEE OK
74801-4845
US

IV. Provider business mailing address

33007 45TH ST
SHAWNEE OK
74804-3429
US

V. Phone/Fax

Practice location:
  • Phone: 405-214-0116
  • Fax: 877-334-8552
Mailing address:
  • Phone: 405-214-0116
  • Fax: 877-334-8552

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number1104
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: