Provider Demographics
NPI:1871932103
Name:FORNETT, KEVIN O'NEAL (PRSS)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:O'NEAL
Last Name:FORNETT
Suffix:
Gender:M
Credentials:PRSS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2100 NW 21ST ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73107-3514
Mailing Address - Country:US
Mailing Address - Phone:405-626-3048
Mailing Address - Fax:
Practice Address - Street 1:2100 NW 21ST ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73107-3514
Practice Address - Country:US
Practice Address - Phone:405-626-3048
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-20
Last Update Date:2014-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst