MEDICARE: MS. KELLY RAE LESLEY M.S.

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	101Y00000X	Counselor

General Provider Information

NPI Number	:	1659678266
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. KELLY RAE LESLEY M.S.

Provider Business Mailing Address
First Line	:	62 WHIPPOORWILL RD
Second Line	:
City	:	PONCA CITY
State	:	OK
Zip	:	74604-6097
Country	:	US
Telephone Number	:	580-716-9335
Fax Number	:

Provider Business Practice Location Address
First Line	:	62 WHIPPOORWILL RD
Second Line	:
City	:	PONCA CITY
State	:	OK
Zip	:	74604-6097
Country	:	US
Telephone Number	:	580-716-9335
Fax Number	:

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

Provider Enumeration Date	:	02/16/2011
Last Update Date	:	03/03/2023

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