Provider Demographics
NPI:1336669795
Name:GREEN, SHAKILA KASHAWN (CMII)
Entity Type:Individual
Prefix:
First Name:SHAKILA
Middle Name:KASHAWN
Last Name:GREEN
Suffix:
Gender:F
Credentials:CMII
Other - Prefix:
Other - First Name:SHAKILA
Other - Middle Name:KASHAWN
Other - Last Name:SORRELLS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CMII
Mailing Address - Street 1:14430 NS 3500
Mailing Address - Street 2:
Mailing Address - City:KONAWA
Mailing Address - State:OK
Mailing Address - Zip Code:74849-4901
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:14430 NS 3500
Practice Address - Street 2:
Practice Address - City:KONAWA
Practice Address - State:OK
Practice Address - Zip Code:74849-4901
Practice Address - Country:US
Practice Address - Phone:580-925-2650
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-26
Last Update Date:2021-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200724510AMedicaid
OK200128860AMedicaid