Provider Demographics
NPI:1497185961
Name:SANGO, KELVIN
Entity type:Individual
Prefix:
First Name:KELVIN
Middle Name:
Last Name:SANGO
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 1:1417 W YOUNG ST
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74127-2721
Mailing Address - Country:US
Mailing Address - Phone:918-361-6135
Mailing Address - Fax:
Practice Address - Street 1:1417 W YOUNG ST
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74127-2721
Practice Address - Country:US
Practice Address - Phone:918-361-6135
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-20
Last Update Date:2013-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health