Provider Demographics
NPI:1760542799
Name:DIAL, SHANNON NICOLE (LMFT)
Entity Type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:NICOLE
Last Name:DIAL
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:CHICKASAW NATION MEDICAL CENTER
Mailing Address - Street 2:1921 STONECIPHER BLVD.
Mailing Address - City:ADA
Mailing Address - State:OK
Mailing Address - Zip Code:74820
Mailing Address - Country:US
Mailing Address - Phone:580-436-3980
Mailing Address - Fax:
Practice Address - Street 1:1921 STONECIPHER BLVD.
Practice Address - Street 2:CHICKASAW NATION MEDICAL CENTER
Practice Address - City:ADA
Practice Address - State:OK
Practice Address - Zip Code:74820
Practice Address - Country:US
Practice Address - Phone:806-793-6160
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-11
Last Update Date:2018-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
TX201371106H00000X
OK1175106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health