Provider Demographics
NPI:1104180736
Name:PRACHT, SHANNON AVERY (MED)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:AVERY
Last Name:PRACHT
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1337 S WINSTON AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74112-6142
Mailing Address - Country:US
Mailing Address - Phone:405-756-6227
Mailing Address - Fax:
Practice Address - Street 1:4300 S HARVARD AVE STE 100
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74135-2608
Practice Address - Country:US
Practice Address - Phone:918-508-2773
Practice Address - Fax:918-508-2789
Is Sole Proprietor?:No
Enumeration Date:2012-06-28
Last Update Date:2013-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional