Healthcare Provider Details

I. General information

NPI: 1801542782
Provider Name (Legal Business Name): STEVEN KEITH ELLIS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/01/2022
Last Update Date: 02/26/2024
Certification Date: 02/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5310 E 31ST ST
TULSA OK
74135-5018
US

IV. Provider business mailing address

4001 S CHESTNUT AVE
BROKEN ARROW OK
74011-1404
US

V. Phone/Fax

Practice location:
  • Phone: 918-600-3100
  • 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: