Provider Demographics
NPI:1154786952
Name:SHERIDAN, KELLI R
Entity type:Individual
Prefix:
First Name:KELLI
Middle Name:R
Last Name:SHERIDAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:157 STONEBRIDGE BLVD APT 2816
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73013-4785
Mailing Address - Country:US
Mailing Address - Phone:405-308-8501
Mailing Address - Fax:
Practice Address - Street 1:157 STONEBRIDGE BLVD APT 2816
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73013-4785
Practice Address - Country:US
Practice Address - Phone:405-308-8501
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-21
Last Update Date:2015-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health