Provider Demographics
NPI:1245571983
Name:SHINE, SHAWNA
Entity Type:Individual
Prefix:
First Name:SHAWNA
Middle Name:
Last Name:SHINE
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 1:2008 N DODSON TER
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73111-1943
Mailing Address - Country:US
Mailing Address - Phone:405-924-5079
Mailing Address - Fax:
Practice Address - Street 1:933 NE 20TH ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73105-8211
Practice Address - Country:US
Practice Address - Phone:405-924-5079
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-05
Last Update Date:2024-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional