Provider Demographics
NPI:1063423994
Name:SHAW, TERRY GLEN (PHD)
Entity type:Individual
Prefix:
First Name:TERRY
Middle Name:GLEN
Last Name:SHAW
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3010
Mailing Address - Street 2:
Mailing Address - City:MCALESTER
Mailing Address - State:OK
Mailing Address - Zip Code:74502-3010
Mailing Address - Country:US
Mailing Address - Phone:918-426-6780
Mailing Address - Fax:918-488-8021
Practice Address - Street 1:7146 S BRADEN
Practice Address - Street 2:SUITE 500
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136
Practice Address - Country:US
Practice Address - Phone:918-488-6165
Practice Address - Fax:918-488-8021
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2013-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK373103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK233520900Medicare ID - Type Unspecified