Provider Demographics
NPI:1427821537
Name:KELLEY, PATRICK WILLIAM
Entity type:Individual
Prefix:
First Name:PATRICK
Middle Name:WILLIAM
Last Name:KELLEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2210 N ELDORADO AVE
Mailing Address - Street 2:
Mailing Address - City:KLAMATH FALLS
Mailing Address - State:OR
Mailing Address - Zip Code:97601-6418
Mailing Address - Country:US
Mailing Address - Phone:541-883-1031
Mailing Address - Fax:
Practice Address - Street 1:101 PARK AVE STE 1300
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73102-7216
Practice Address - Country:US
Practice Address - Phone:405-689-9820
Practice Address - Fax:855-915-1521
Is Sole Proprietor?:No
Enumeration Date:2023-10-31
Last Update Date:2024-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
OKRBT-24-375242106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No171M00000XOther Service ProvidersCase Manager/Care Coordinator