Provider Demographics
NPI:1083679658
Name:MARSHALL, KELLI BROOKE (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:KELLI
Middle Name:BROOKE
Last Name:MARSHALL
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2612 SE 39TH ST
Mailing Address - Street 2:
Mailing Address - City:MOORE
Mailing Address - State:OK
Mailing Address - Zip Code:73160-0642
Mailing Address - Country:US
Mailing Address - Phone:405-378-2929
Mailing Address - Fax:866-435-3297
Practice Address - Street 1:5500 N WESTERN AVE
Practice Address - Street 2:SUITE 153
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73118-4019
Practice Address - Country:US
Practice Address - Phone:405-286-3749
Practice Address - Fax:866-435-3297
Is Sole Proprietor?:No
Enumeration Date:2006-04-18
Last Update Date:2011-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3036235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200063320BMedicaid