Provider Demographics
NPI:1033409099
Name:MOORE, SHAWNA DONISE (PSYD, LPC, BCBA)
Entity Type:Individual
Prefix:
First Name:SHAWNA
Middle Name:DONISE
Last Name:MOORE
Suffix:
Gender:F
Credentials:PSYD, LPC, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2118 N MANNING ST
Mailing Address - Street 2:
Mailing Address - City:STILLWATER
Mailing Address - State:OK
Mailing Address - Zip Code:74075-2950
Mailing Address - Country:US
Mailing Address - Phone:405-824-3408
Mailing Address - Fax:405-564-0062
Practice Address - Street 1:614 S MAIN ST
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:OK
Practice Address - Zip Code:74074-4059
Practice Address - Country:US
Practice Address - Phone:405-824-3408
Practice Address - Fax:405-564-0062
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-12
Last Update Date:2020-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1-15017996103K00000X
OK4885101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty