Provider Demographics
NPI:1285094193
Name:LAYNE, KERRIS
Entity type:Individual
Prefix:
First Name:KERRIS
Middle Name:
Last Name:LAYNE
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:PO BOX 6211
Mailing Address - Street 2:
Mailing Address - City:MOORE
Mailing Address - State:OK
Mailing Address - Zip Code:73153-0211
Mailing Address - Country:US
Mailing Address - Phone:405-339-2097
Mailing Address - Fax:
Practice Address - Street 1:7141 S WESTERN AVE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73139-2000
Practice Address - Country:US
Practice Address - Phone:405-339-2097
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-04
Last Update Date:2017-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YP2500X
OK00000000000000000000101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor