Provider Demographics
NPI:1679923320
Name:KENNEDY-GONZALEZ, SHELLY MARIE (LPC)
Entity type:Individual
Prefix:
First Name:SHELLY
Middle Name:MARIE
Last Name:KENNEDY-GONZALEZ
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:SHELLY
Other - Middle Name:
Other - Last Name:BILBY-LOGAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6931 S 66TH EAST AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74133-1765
Mailing Address - Country:US
Mailing Address - Phone:918-379-4431
Mailing Address - Fax:918-328-2380
Practice Address - Street 1:6931 S 66TH EAST AVE STE 200
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74133-1765
Practice Address - Country:US
Practice Address - Phone:918-379-4431
Practice Address - Fax:918-328-2380
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-14
Last Update Date:2024-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK6888101YA0400X
OK101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)