Provider Demographics
NPI:1316123946
Name:SHADLOW, JOANNA OMEGA (PHD)
Entity type:Individual
Prefix:DR
First Name:JOANNA
Middle Name:OMEGA
Last Name:SHADLOW
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:550 S PEORIA AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74120-3820
Mailing Address - Country:US
Mailing Address - Phone:918-588-1900
Mailing Address - Fax:918-582-6405
Practice Address - Street 1:550 S PEORIA AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74120-3820
Practice Address - Country:US
Practice Address - Phone:918-588-1900
Practice Address - Fax:918-582-6405
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-14
Last Update Date:2015-06-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OK1172103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100732910-GOtherGROUP MEDICAID/SOONERCARE
OK73-1042545OtherGROUP COMMUNITY CARE OF OKLAHOMA
OK73-1042545OtherGROUP MEDICARE
OK73-1042545OtherGROUP BCBS
OK731042545001OtherGROUP TRICARE
OK100732910-AOtherGROUP MEDICAID/SOONERCARE