Healthcare Provider Details

I. General information

NPI: 1821662610
Provider Name (Legal Business Name): MIRANDA SHELTON MSW-P
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2021
Last Update Date: 06/28/2024
Certification Date: 06/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

604 S WALNUT ST
STILLWATER OK
74074-4222
US

IV. Provider business mailing address

604 S WALNUT ST
STILLWATER OK
74074-4222
US

V. Phone/Fax

Practice location:
  • Phone: 918-313-2261
  • Fax:
Mailing address:
  • Phone: 918-313-2261
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number20927-P
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: