Provider Demographics
NPI:1215559232
Name:SHOUSE, BRANDI NICOLE
Entity Type:Individual
Prefix:
First Name:BRANDI
Middle Name:NICOLE
Last Name:SHOUSE
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 1:105 STONERIDGE RD
Mailing Address - Street 2:
Mailing Address - City:MORRISON
Mailing Address - State:OK
Mailing Address - Zip Code:73061-5800
Mailing Address - Country:US
Mailing Address - Phone:405-714-2804
Mailing Address - Fax:
Practice Address - Street 1:105 STONERIDGE RD
Practice Address - Street 2:
Practice Address - City:MORRISON
Practice Address - State:OK
Practice Address - Zip Code:73061-5800
Practice Address - Country:US
Practice Address - Phone:405-714-2804
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-13
Last Update Date:2020-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator