Provider Demographics
NPI:1629632187
Name:ROBERTS, SHAWN DOUGLAS
Entity Type:Individual
Prefix:
First Name:SHAWN
Middle Name:DOUGLAS
Last Name:ROBERTS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:910 SW E AVE
Mailing Address - Street 2:
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73501-4593
Mailing Address - Country:US
Mailing Address - Phone:580-699-5550
Mailing Address - Fax:
Practice Address - Street 1:910 SW E AVE
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73501-4593
Practice Address - Country:US
Practice Address - Phone:580-699-5550
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-30
Last Update Date:2019-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling