Provider Demographics
NPI:1396062873
Name:SULLIVAN, KEITH ALAN
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:ALAN
Last Name:SULLIVAN
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 1:5005 N PENNSYLVANIA AVE
Mailing Address - Street 2:103
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73112-8886
Mailing Address - Country:US
Mailing Address - Phone:405-753-4269
Mailing Address - Fax:
Practice Address - Street 1:5005 N PENNSYLVANIA AVE
Practice Address - Street 2:103
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73112-8886
Practice Address - Country:US
Practice Address - Phone:405-753-4269
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-23
Last Update Date:2010-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK77-0700929261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)