Provider Demographics
NPI:1265706428
Name:SELF, SHELLY M (LPC)
Entity type:Individual
Prefix:
First Name:SHELLY
Middle Name:M
Last Name:SELF
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:704 SHIRLEY LN
Mailing Address - Street 2:
Mailing Address - City:MADILL
Mailing Address - State:OK
Mailing Address - Zip Code:73446-9772
Mailing Address - Country:US
Mailing Address - Phone:580-238-0506
Mailing Address - Fax:
Practice Address - Street 1:301 W MAIN ST
Practice Address - Street 2:STE 324
Practice Address - City:ARDMORE
Practice Address - State:OK
Practice Address - Zip Code:73401-6337
Practice Address - Country:US
Practice Address - Phone:580-238-0506
Practice Address - Fax:580-238-0506
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-05
Last Update Date:2015-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200049040CMedicaid