Provider Demographics
NPI:1811417934
Name:SHORT, ANGELA RENEE
Entity Type:Individual
Prefix:MS
First Name:ANGELA
Middle Name:RENEE
Last Name:SHORT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ANGELA
Other - Middle Name:RENEE
Other - Last Name:SHEPHERD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:23110 E 67TH ST S
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74014-2103
Mailing Address - Country:US
Mailing Address - Phone:918-630-4663
Mailing Address - Fax:
Practice Address - Street 1:2121 S 125TH EAST AVE STE 106
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74129-5800
Practice Address - Country:US
Practice Address - Phone:918-574-8442
Practice Address - Fax:918-591-3955
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-20
Last Update Date:2024-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251B00000X
OK311698261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No251B00000XAgenciesCase Management