Provider Demographics
NPI:1962787580
Name:DEATHERAGE, KENI (BA, BHRS)
Entity type:Individual
Prefix:MISS
First Name:KENI
Middle Name:
Last Name:DEATHERAGE
Suffix:
Gender:F
Credentials:BA, BHRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1005 CORONET CIR
Mailing Address - Street 2:
Mailing Address - City:HEAVENER
Mailing Address - State:OK
Mailing Address - Zip Code:74937-3806
Mailing Address - Country:US
Mailing Address - Phone:479-462-9818
Mailing Address - Fax:
Practice Address - Street 1:1005 CORONET CIR
Practice Address - Street 2:
Practice Address - City:HEAVENER
Practice Address - State:OK
Practice Address - Zip Code:74937-3806
Practice Address - Country:US
Practice Address - Phone:479-462-9818
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-14
Last Update Date:2011-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitation