Healthcare Provider Details

I. General information

NPI: 1629305776
Provider Name (Legal Business Name): SHANNON NEVADA FAIRLESS BSW, CMII
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/11/2009
Last Update Date: 06/04/2024
Certification Date: 06/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1222 10TH ST
WOODWARD OK
73801-3156
US

IV. Provider business mailing address

1222 10TH ST
WOODWARD OK
73801-3156
US

V. Phone/Fax

Practice location:
  • Phone: 580-256-8615
  • Fax:
Mailing address:
  • Phone: 802-568-6155
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: