Provider Demographics
NPI:1346579836
Name:SHIRLEY, TAMMY SUE (BACHELOR-BA)
Entity Type:Individual
Prefix:
First Name:TAMMY
Middle Name:SUE
Last Name:SHIRLEY
Suffix:
Gender:F
Credentials:BACHELOR-BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:406WESTCHICKASAW
Mailing Address - Street 2:202SOUTHWASHITA
Mailing Address - City:WYNNEWOOD
Mailing Address - State:OK
Mailing Address - Zip Code:73098
Mailing Address - Country:US
Mailing Address - Phone:405-665-2540
Mailing Address - Fax:
Practice Address - Street 1:406WESTCHICKASAWWYNNEWOOD,OKLAHOMA73098
Practice Address - Street 2:202SOUTHWASHITA
Practice Address - City:WYNNEWOOD
Practice Address - State:OK
Practice Address - Zip Code:73098
Practice Address - Country:US
Practice Address - Phone:405-665-2540
Practice Address - Fax:405-665-6396
Is Sole Proprietor?:No
Enumeration Date:2009-12-14
Last Update Date:2009-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK103K0000X103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKP5A4G5E4Medicaid