Provider Demographics
NPI:1407672371
Name:MOAK, KYLIE MICHELLE (MASTERS STUDENT)
Entity type:Individual
Prefix:
First Name:KYLIE
Middle Name:MICHELLE
Last Name:MOAK
Suffix:
Gender:F
Credentials:MASTERS STUDENT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3841 NW 24TH ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73107-1403
Mailing Address - Country:US
Mailing Address - Phone:720-756-5715
Mailing Address - Fax:
Practice Address - Street 1:6448 S WESTERN AVE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73139-1717
Practice Address - Country:US
Practice Address - Phone:405-939-5800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-25
Last Update Date:2024-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health