Provider Demographics
NPI:1417274655
Name:GILLS-ROBERSON, SHAUNTA
Entity Type:Individual
Prefix:
First Name:SHAUNTA
Middle Name:
Last Name:GILLS-ROBERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SHAUNTA
Other - Middle Name:
Other - Last Name:GILLS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 721627
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73172-1627
Mailing Address - Country:US
Mailing Address - Phone:405-684-3104
Mailing Address - Fax:
Practice Address - Street 1:1016 SW 44TH ST STE 500
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73109-3615
Practice Address - Country:US
Practice Address - Phone:405-605-4249
Practice Address - Fax:405-605-0255
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-28
Last Update Date:2020-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK5917101Y00000X
101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200360060AMedicaid