Provider Demographics
NPI:1336382217
Name:SIMON, SHELLEY G (LCSW)
Entity Type:Individual
Prefix:
First Name:SHELLEY
Middle Name:G
Last Name:SIMON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:SHELLEY
Other - Middle Name:G
Other - Last Name:DAVIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:212 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:OK
Mailing Address - Zip Code:74637-3023
Mailing Address - Country:US
Mailing Address - Phone:918-642-3100
Mailing Address - Fax:918-642-5639
Practice Address - Street 1:212 N MAIN ST
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:OK
Practice Address - Zip Code:74637-3023
Practice Address - Country:US
Practice Address - Phone:918-642-3100
Practice Address - Fax:918-642-5639
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-08
Last Update Date:2017-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK30491041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK394452YRHZOtherGROUP PTAN
OK200240990AMedicaid