Provider Demographics
NPI:1073817565
Name:TUCKER, SHANNON RENEE
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:RENEE
Last Name:TUCKER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7777 E US HIGHWAY 66
Mailing Address - Street 2:
Mailing Address - City:EL RENO
Mailing Address - State:OK
Mailing Address - Zip Code:73036-9125
Mailing Address - Country:US
Mailing Address - Phone:405-422-8800
Mailing Address - Fax:405-422-8818
Practice Address - Street 1:7777 E US HIGHWAY 66
Practice Address - Street 2:
Practice Address - City:EL RENO
Practice Address - State:OK
Practice Address - Zip Code:73036-9125
Practice Address - Country:US
Practice Address - Phone:405-422-8800
Practice Address - Fax:405-422-8818
Is Sole Proprietor?:No
Enumeration Date:2010-12-27
Last Update Date:2010-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health