MEDICARE: MS. BETHANY LOUISE KELLY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103K00000X	Behavior Analyst

General Provider Information

NPI Number	:	1538418140
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. BETHANY LOUISE KELLY

Provider Business Mailing Address
First Line	:	11753 S 86TH EAST AVE
Second Line	:
City	:	BIXBY
State	:	OK
Zip	:	74008-2101
Country	:	US
Telephone Number	:	918-760-8129
Fax Number	:

Provider Business Practice Location Address
First Line	:	6216 SOUTH LEWIS AVENUE
Second Line	:
City	:	TULSA
State	:	OK
Zip	:	74136
Country	:	US
Telephone Number	:	918-960-7852
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/29/2012
Last Update Date	:	02/14/2020

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