Provider Demographics
NPI:1902898000
Name:KALIES, KURT E (AUD)
Entity type:Individual
Prefix:
First Name:KURT
Middle Name:E
Last Name:KALIES
Suffix:
Gender:M
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3954 N. KICKAPOO AVE
Mailing Address - Street 2:
Mailing Address - City:SHAWNEE
Mailing Address - State:OK
Mailing Address - Zip Code:74804
Mailing Address - Country:US
Mailing Address - Phone:405-273-6203
Mailing Address - Fax:
Practice Address - Street 1:3954 N. KICKAPOO AVE
Practice Address - Street 2:
Practice Address - City:SHAWNEE
Practice Address - State:OK
Practice Address - Zip Code:74804
Practice Address - Country:US
Practice Address - Phone:405-273-6203
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-16
Last Update Date:2016-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK139231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100659350AMedicaid