Healthcare Provider Details

I. General information

NPI: 1760542799
Provider Name (Legal Business Name): SHANNON NICOLE DIAL LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/11/2006
Last Update Date: 09/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1921 STONECIPHER BLVD. CHICKASAW NATION MEDICAL CENTER
ADA OK
74820
US

IV. Provider business mailing address

CHICKASAW NATION MEDICAL CENTER 1921 STONECIPHER BLVD.
ADA OK
74820
US

V. Phone/Fax

Practice location:
  • Phone: 806-793-6160
  • Fax:
Mailing address:
  • Phone: 580-436-3980
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number201371
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number1175
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: