1265706428 NPI number — SHELLY M SELF LPC

Table of content: SHELLY M SELF LPC (NPI 1265706428)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265706428 NPI number — SHELLY M SELF LPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SELF
Provider First Name:
SHELLY
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LPC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1265706428
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/09/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
704 SHIRLEY LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MADILL
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
73446-9772
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
580-238-0506
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
301 W MAIN ST
Provider Second Line Business Practice Location Address:
STE 324
Provider Business Practice Location Address City Name:
ARDMORE
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
73401-6337
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
580-238-0506
Provider Business Practice Location Address Fax Number:
580-238-0506
Provider Enumeration Date:
03/05/2012

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 200049040C , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".




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