Individual
KELLY DIVINE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Contact information
Practice address
511 E 2ND ST, HEAVENER, OK 74937-3419
(918) 653-7718
Mailing address
PO BOX 846, HEAVENER, OK 74937-0846
Taxonomy
Speciality
Code
Description
License number
State
101YM0800X
Mental Health Counselor
Primary
—
—
Other
Enumeration date
01/05/2017
Last updated
01/05/2017
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