Provider Demographics
NPI:1629547286
Name:OLIVER, KEALEY JORDAN (OTR)
Entity Type:Individual
Prefix:
First Name:KEALEY
Middle Name:JORDAN
Last Name:OLIVER
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3223 E. 31ST STEET
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74105
Mailing Address - Country:US
Mailing Address - Phone:918-250-7093
Mailing Address - Fax:918-250-9976
Practice Address - Street 1:3223 E. 31ST STEET
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74105
Practice Address - Country:US
Practice Address - Phone:918-250-7093
Practice Address - Fax:918-250-9976
Is Sole Proprietor?:No
Enumeration Date:2018-11-13
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2018024369225X00000X
OK5225225X00000X
225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200910860AMedicaid