MEDICARE: WILLIAM RANDAL SHANAHAN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor		OK

General Provider Information

NPI Number	:	1538270657
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	WILLIAM RANDAL SHANAHAN

Provider Business Mailing Address
First Line	:	724 PENN LN
Second Line	:
City	:	MOORE
State	:	OK
Zip	:	73160-2441
Country	:	US
Telephone Number	:	405-524-6500
Fax Number	:	405-524-6515

Provider Business Practice Location Address
First Line	:	2240 NW 39TH ST
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73112-8884
Country	:	US
Telephone Number	:	405-524-6500
Fax Number	:	405-524-6515

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/31/2006
Last Update Date	:	07/08/2007

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