Basic Information
| Provider Information | |||||||||
| NPI: | 1346579836 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHIRLEY | ||||||||
| FirstName: | TAMMY | ||||||||
| MiddleName: | SUE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | BACHELOR-BA | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 406WESTCHICKASAW | ||||||||
| Address2: | 202SOUTHWASHITA | ||||||||
| City: | WYNNEWOOD | ||||||||
| State: | OK | ||||||||
| PostalCode: | 73098 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4056652540 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 406WESTCHICKASAWWYNNEWOOD,OKLAHOMA73098 | ||||||||
| Address2: | 202SOUTHWASHITA | ||||||||
| City: | WYNNEWOOD | ||||||||
| State: | OK | ||||||||
| PostalCode: | 73098 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4056652540 | ||||||||
| FaxNumber: | 4056656396 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/14/2009 | ||||||||
| LastUpdateDate: | 12/14/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | 103K0000X | OK | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
ID Information
| ID | Type | State | Issuer | Description | P5A4G5E4 | 05 | OK | MEDICAID |