Provider Demographics
NPI:1891210142
Name:BROWN, SHELLY JANAE
Entity Type:Individual
Prefix:
First Name:SHELLY
Middle Name:JANAE
Last Name:BROWN
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:SHELLY
Other - Middle Name:JANAE
Other - Last Name:FRANCISCO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:405 E EXCELSIOR AVE
Mailing Address - Street 2:
Mailing Address - City:VINITA
Mailing Address - State:OK
Mailing Address - Zip Code:74301-4226
Mailing Address - Country:US
Mailing Address - Phone:918-256-3628
Mailing Address - Fax:
Practice Address - Street 1:405 E EXCELSIOR AVE
Practice Address - Street 2:
Practice Address - City:VINITA
Practice Address - State:OK
Practice Address - Zip Code:74301
Practice Address - Country:US
Practice Address - Phone:918-256-6476
Practice Address - Fax:918-256-3628
Is Sole Proprietor?:No
Enumeration Date:2017-08-08
Last Update Date:2019-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2018034379101YP2500X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional