Provider Demographics
NPI:1053558379
Name:SELF, SHEILA J (MS, LPC)
Entity type:Individual
Prefix:
First Name:SHEILA
Middle Name:J
Last Name:SELF
Suffix:
Gender:F
Credentials:MS, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 N GRAND AVENUE
Mailing Address - Street 2:NORTHEASTERN STATE UNIVERSITY OFFICE OF STUDENT AFFAIRS
Mailing Address - City:TAHLEQUAH
Mailing Address - State:OK
Mailing Address - Zip Code:74464
Mailing Address - Country:US
Mailing Address - Phone:918-444-2120
Mailing Address - Fax:918-458-2340
Practice Address - Street 1:601 N GRAND AVE
Practice Address - Street 2:
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74464-2302
Practice Address - Country:US
Practice Address - Phone:918-444-2120
Practice Address - Fax:918-445-8234
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-08
Last Update Date:2009-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3357101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional