Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 103TR0400X | Rehabilitation Psychologist | W081093352 | OK |
NPI | 1073859047 |
---|---|
Provider Name | Mrs. Shelley Kay Johnson |
First Address | Tishomingo, OK 73460-2351 |
Second Address | Tishomingo, OK 73460-2351 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 19/12/2012 |
Last Update Date | 19/12/2012 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
200226970A | (05) | OK |