Provider Demographics
NPI:1962936344
Name:STONE, SHANDRA R (LMSW UNDER SUPERVISI)
Entity type:Individual
Prefix:
First Name:SHANDRA
Middle Name:R
Last Name:STONE
Suffix:
Gender:F
Credentials:LMSW UNDER SUPERVISI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3103 E JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:HUGO
Mailing Address - State:OK
Mailing Address - Zip Code:74743-4051
Mailing Address - Country:US
Mailing Address - Phone:580-326-5279
Mailing Address - Fax:580-326-8047
Practice Address - Street 1:3103 E JACKSON ST
Practice Address - Street 2:
Practice Address - City:HUGO
Practice Address - State:OK
Practice Address - Zip Code:74743-4051
Practice Address - Country:US
Practice Address - Phone:580-326-5279
Practice Address - Fax:580-326-8047
Is Sole Proprietor?:No
Enumeration Date:2017-04-12
Last Update Date:2017-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200493040AMedicaid