Provider Demographics
NPI:1619496858
Name:MULDER, SHELBY K
Entity Type:Individual
Prefix:
First Name:SHELBY
Middle Name:K
Last Name:MULDER
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 1:2727 S 137TH WEST AVE
Mailing Address - Street 2:
Mailing Address - City:SAND SPRINGS
Mailing Address - State:OK
Mailing Address - Zip Code:74063-5017
Mailing Address - Country:US
Mailing Address - Phone:918-245-0231
Mailing Address - Fax:
Practice Address - Street 1:2727 S 137TH WEST AVE
Practice Address - Street 2:
Practice Address - City:SAND SPRINGS
Practice Address - State:OK
Practice Address - Zip Code:74063-5017
Practice Address - Country:US
Practice Address - Phone:918-245-0231
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-19
Last Update Date:2021-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK171M00000X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health