Provider Demographics
NPI:1790798130
Name:BRUE, SHAWN ALLEN (MMFT LPC LMFT)
Entity Type:Individual
Prefix:MR
First Name:SHAWN
Middle Name:ALLEN
Last Name:BRUE
Suffix:
Gender:M
Credentials:MMFT LPC LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5002 SW LEE BLVD
Mailing Address - Street 2:
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73505-8320
Mailing Address - Country:US
Mailing Address - Phone:580-531-4512
Mailing Address - Fax:580-531-4519
Practice Address - Street 1:5002 SW LEE BLVD
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73505-8320
Practice Address - Country:US
Practice Address - Phone:580-531-4512
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2011-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKOK LPC 1266101YM0800X
OKOK LMFT 734106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health