Provider Demographics
NPI:1104396597
Name:CLARK, SHELBEY DAWN
Entity type:Individual
Prefix:
First Name:SHELBEY
Middle Name:DAWN
Last Name:CLARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2816 PINTO TRL
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73012-6689
Mailing Address - Country:US
Mailing Address - Phone:405-508-4354
Mailing Address - Fax:
Practice Address - Street 1:2816 PINTO TRL
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73012-6689
Practice Address - Country:US
Practice Address - Phone:405-508-4354
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-28
Last Update Date:2024-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X, 171M00000X
OK106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No171M00000XOther Service ProvidersCase Manager/Care Coordinator