Healthcare Provider Details

I. General information

NPI: 1649650599
Provider Name (Legal Business Name): GERALD KEENE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/05/2015
Last Update Date: 06/05/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1870 S BOULDER AVE
TULSA OK
74119-5234
US

IV. Provider business mailing address

252 W 17TH PL
TULSA OK
74119-4654
US

V. Phone/Fax

Practice location:
  • Phone: 918-585-1213
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: