Healthcare Provider Details

I. General information

NPI: 1437117066
Provider Name (Legal Business Name): KEVIN WILLIAM HERAUF OTRL CHT
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/03/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1310 E 15TH ST
TULSA OK
74120
US

IV. Provider business mailing address

11707 SOUTH GUM AVE
JENKS OK
74037
US

V. Phone/Fax

Practice location:
  • Phone: 918-599-0440
  • Fax: 918-599-7774
Mailing address:
  • Phone: 918-296-5309
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XH1200X
TaxonomyHand Occupational Therapist
License Number1359
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: