Provider Demographics
NPI:1477306256
Name:ELLISON, KEELEN D
Entity Type:Individual
Prefix:
First Name:KEELEN
Middle Name:D
Last Name:ELLISON
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:OLD HIGHWAY 33-2000
Mailing Address - Street 2:COMMONS APT 19A
Mailing Address - City:LANGSTON
Mailing Address - State:OK
Mailing Address - Zip Code:73050
Mailing Address - Country:US
Mailing Address - Phone:817-243-9129
Mailing Address - Fax:
Practice Address - Street 1:126 S CENTER ST
Practice Address - Street 2:UPLIFT
Practice Address - City:SHAWNEE
Practice Address - State:OK
Practice Address - Zip Code:74801
Practice Address - Country:US
Practice Address - Phone:817-243-9129
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-10
Last Update Date:2024-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator