Healthcare Provider Details

I. General information

NPI: 1346680360
Provider Name (Legal Business Name): SHELLY D KANTOR MS, LADC/MH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/05/2013
Last Update Date: 11/28/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1516 N LYNN RIGGS BLVD STE 100
CLAREMORE OK
74017-3567
US

IV. Provider business mailing address

7010 S YALE AVE SUITE 215
TULSA OK
74136-5713
US

V. Phone/Fax

Practice location:
  • Phone: 918-923-3802
  • Fax: 918-923-3801
Mailing address:
  • Phone: 918-492-2554
  • Fax: 918-494-9870

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number1336
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number1336
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: