Healthcare Provider Details

I. General information

NPI: 1477306256
Provider Name (Legal Business Name): KEELEN D ELLISON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/10/2024
Last Update Date: 10/07/2024
Certification Date: 10/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

805 E ROBINSON ST
NORMAN OK
73071-6610
US

IV. Provider business mailing address

3313 NE 14TH PL
OKLAHOMA CITY OK
73117-6211
US

V. Phone/Fax

Practice location:
  • Phone: 405-447-4499
  • Fax:
Mailing address:
  • Phone: 817-243-9129
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: