Provider Demographics
NPI:1225434251
Name:SHIVERS, TERESA (MASTERS ED)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:
Last Name:SHIVERS
Suffix:
Gender:F
Credentials:MASTERS ED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:48595 WOLVERINE RD
Mailing Address - Street 2:
Mailing Address - City:PRAGUE
Mailing Address - State:OK
Mailing Address - Zip Code:74864-1250
Mailing Address - Country:US
Mailing Address - Phone:405-590-8584
Mailing Address - Fax:
Practice Address - Street 1:1605 N HARRISON ST
Practice Address - Street 2:
Practice Address - City:SHAWNEE
Practice Address - State:OK
Practice Address - Zip Code:74804-4022
Practice Address - Country:US
Practice Address - Phone:405-481-7187
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-19
Last Update Date:2014-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator