Provider Demographics
NPI:1336659531
Name:KELLY, STEVE A SR
Entity Type:Individual
Prefix:MR
First Name:STEVE
Middle Name:A
Last Name:KELLY
Suffix:SR
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 1:10 SAHOMA LAKE RD
Mailing Address - Street 2:
Mailing Address - City:SAPULPA
Mailing Address - State:OK
Mailing Address - Zip Code:74066-6741
Mailing Address - Country:US
Mailing Address - Phone:918-269-9106
Mailing Address - Fax:
Practice Address - Street 1:10 SAHOMA LAKE RD
Practice Address - Street 2:
Practice Address - City:SAPULPA
Practice Address - State:OK
Practice Address - Zip Code:74066-6741
Practice Address - Country:US
Practice Address - Phone:918-269-9105
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-03
Last Update Date:2017-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator