Basic Information
| Provider Information | |||||||||
| NPI: | 1538457569 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CROWDER | ||||||||
| FirstName: | SHONTA | ||||||||
| MiddleName: | YANETTE | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3492 | ||||||||
| Address2: | |||||||||
| City: | BARTLESVILLE | ||||||||
| State: | OK | ||||||||
| PostalCode: | 740063492 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9187666998 | ||||||||
| FaxNumber: | 9188766030 | ||||||||
| Practice Location | |||||||||
| Address1: | 3606 IDAHO AVE | ||||||||
| Address2: | |||||||||
| City: | BARTLESVILLE | ||||||||
| State: | OK | ||||||||
| PostalCode: | 740062420 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9183378080 | ||||||||
| FaxNumber: | 9183378099 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2011 | ||||||||
| LastUpdateDate: | 05/07/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 05/07/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health | 1041C0700X | 5264 | OK | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 104100000X | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.