Provider Demographics
NPI:1497378442
Name:MORAN, BRIAN KEITH (OTA)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:KEITH
Last Name:MORAN
Suffix:
Gender:M
Credentials:OTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:231 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MARLOW
Mailing Address - State:OK
Mailing Address - Zip Code:73055-2439
Mailing Address - Country:US
Mailing Address - Phone:580-721-7100
Mailing Address - Fax:
Practice Address - Street 1:231 W MAIN ST
Practice Address - Street 2:
Practice Address - City:MARLOW
Practice Address - State:OK
Practice Address - Zip Code:73055-2439
Practice Address - Country:US
Practice Address - Phone:580-721-7100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-26
Last Update Date:2020-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK850224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OTHEROtherOTHER