Healthcare Provider Details

I. General information

NPI: 1629793757
Provider Name (Legal Business Name): SHAWNA ROBERSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/11/2022
Last Update Date: 03/02/2023
Certification Date: 03/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4103 S YALE AVE STE B
TULSA OK
74135-6002
US

IV. Provider business mailing address

19320 E ADMIRAL PL STE B
CATOOSA OK
74015-3240
US

V. Phone/Fax

Practice location:
  • Phone: 918-382-7300
  • Fax:
Mailing address:
  • Phone: 918-340-5503
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLPCCANDIDATE11328
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: