Provider Demographics
NPI:1043411077
Name:KELTNER, THOMAS MARK
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:MARK
Last Name:KELTNER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 218
Mailing Address - Street 2:
Mailing Address - City:BOLEY
Mailing Address - State:OK
Mailing Address - Zip Code:74829-0218
Mailing Address - Country:US
Mailing Address - Phone:918-667-3367
Mailing Address - Fax:918-667-3387
Practice Address - Street 1:2 MILES EAST OF BOLEY ON HWY 62
Practice Address - Street 2:
Practice Address - City:BOLEY
Practice Address - State:OK
Practice Address - Zip Code:74829
Practice Address - Country:US
Practice Address - Phone:918-667-3367
Practice Address - Fax:918-667-3387
Is Sole Proprietor?:No
Enumeration Date:2007-05-29
Last Update Date:2010-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100685660AMedicaid
OK100685660DMedicaid