Provider Demographics
NPI:1336470400
Name:MCCLEARY, SHANNON NIKOLE (BHRS)
Entity Type:Individual
Prefix:MS
First Name:SHANNON
Middle Name:NIKOLE
Last Name:MCCLEARY
Suffix:
Gender:F
Credentials:BHRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 NW 146TH ST
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73013-2446
Mailing Address - Country:US
Mailing Address - Phone:405-924-3448
Mailing Address - Fax:
Practice Address - Street 1:300 NW 146TH ST
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73013-2446
Practice Address - Country:US
Practice Address - Phone:405-924-3448
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-28
Last Update Date:2010-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK$$$$$$$$$Medicaid