Provider Demographics
NPI:1629528302
Name:DEATHERAGE, SHANNON (BSW)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:DEATHERAGE
Suffix:
Gender:F
Credentials:BSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2119 HAWK CIR
Mailing Address - Street 2:
Mailing Address - City:ADA
Mailing Address - State:OK
Mailing Address - Zip Code:74820-6001
Mailing Address - Country:US
Mailing Address - Phone:580-332-6345
Mailing Address - Fax:580-421-7724
Practice Address - Street 1:3115 ARLINGTON ST
Practice Address - Street 2:
Practice Address - City:ADA
Practice Address - State:OK
Practice Address - Zip Code:74820-3085
Practice Address - Country:US
Practice Address - Phone:580-332-6345
Practice Address - Fax:580-421-7724
Is Sole Proprietor?:No
Enumeration Date:2016-10-06
Last Update Date:2016-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker