=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487925335
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SANDRA L. REESE-KECK BCBA, LPC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/24/2012
-----------------------------------------------------
Last Update Date | 10/21/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 729 OVERLAND TRAIL
-----------------------------------------------------
City | ENID
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73703
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 580-540-4163
-----------------------------------------------------
Fax | 580-294-5204
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 729 OVERLAND TRAIL
-----------------------------------------------------
City | ENID
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73703
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 580-540-4163
-----------------------------------------------------
Fax | 580-294-5204
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 6531
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103K00000X
-----------------------------------------------------
Taxonomy Name | Behavior Analyst
-----------------------------------------------------
License Number | 1-11-9464
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------