Provider Demographics
NPI:1053630848
Name:SHOALS, TIMOTHY LEE (BA)
Entity Type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:LEE
Last Name:SHOALS
Suffix:
Gender:M
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:214 SW 30TH ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73109-6506
Mailing Address - Country:US
Mailing Address - Phone:405-272-1610
Mailing Address - Fax:405-272-1630
Practice Address - Street 1:214 SW 30TH ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73109-6506
Practice Address - Country:US
Practice Address - Phone:405-272-1610
Practice Address - Fax:405-272-1630
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-19
Last Update Date:2010-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health