Provider Demographics
NPI:1750684098
Name:JOHNSON, SHELLY
Entity Type:Individual
Prefix:
First Name:SHELLY
Middle Name:
Last Name:JOHNSON
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 1:3301 CHEEK PL
Mailing Address - Street 2:
Mailing Address - City:DEL CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73115-1627
Mailing Address - Country:US
Mailing Address - Phone:405-246-8202
Mailing Address - Fax:
Practice Address - Street 1:3301 CHEEK PL
Practice Address - Street 2:
Practice Address - City:DEL CITY
Practice Address - State:OK
Practice Address - Zip Code:73115-1627
Practice Address - Country:US
Practice Address - Phone:405-246-8202
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-08
Last Update Date:2013-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health