Provider Demographics
NPI:1093038895
Name:UNDERWOOD, LA SHAWN MARIE (MHR, LPC)
Entity Type:Individual
Prefix:
First Name:LA SHAWN
Middle Name:MARIE
Last Name:UNDERWOOD
Suffix:
Gender:F
Credentials:MHR, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1901 NW 174TH ST
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73012-7068
Mailing Address - Country:US
Mailing Address - Phone:405-529-6331
Mailing Address - Fax:
Practice Address - Street 1:5120 N SANTA FE AVE STE C
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73118-7510
Practice Address - Country:US
Practice Address - Phone:405-529-6331
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-08
Last Update Date:2018-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK6225101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200352330AMedicaid