Provider Demographics
NPI:1760730931
Name:WILLIS, SHELBY ERIN
Entity Type:Individual
Prefix:MRS
First Name:SHELBY
Middle Name:ERIN
Last Name:WILLIS
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 1:624 FAIRLANE DR
Mailing Address - Street 2:
Mailing Address - City:MIDWEST CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73110-1626
Mailing Address - Country:US
Mailing Address - Phone:405-600-4145
Mailing Address - Fax:
Practice Address - Street 1:624 FAIRLANE DR
Practice Address - Street 2:
Practice Address - City:MIDWEST CITY
Practice Address - State:OK
Practice Address - Zip Code:73110-1626
Practice Address - Country:US
Practice Address - Phone:405-600-4145
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-20
Last Update Date:2012-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1972880300101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200427950AOtherKREATIVE BEHAVIORAL HEALTH SERVICES