Provider Demographics
NPI:1124397484
Name:NORWOOD, SHANE STEPHEN
Entity Type:Individual
Prefix:
First Name:SHANE
Middle Name:STEPHEN
Last Name:NORWOOD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:624 COUNTRY SIDE TRL
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73012-6686
Mailing Address - Country:US
Mailing Address - Phone:405-863-8308
Mailing Address - Fax:
Practice Address - Street 1:4400 N LINCOLN BLVD
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73105-5104
Practice Address - Country:US
Practice Address - Phone:405-424-7711
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-15
Last Update Date:2011-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health