Healthcare Provider Details

I. General information

NPI: 1972930816
Provider Name (Legal Business Name): KEMBARLY MCNEILL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/10/2013
Last Update Date: 10/10/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6202 S LEWIS AVE STE M
TULSA OK
74136-1064
US

IV. Provider business mailing address

321 W UTICA PL
BROKEN ARROW OK
74011-2460
US

V. Phone/Fax

Practice location:
  • Phone: 918-949-4086
  • Fax:
Mailing address:
  • Phone: 918-906-5749
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: