Provider Demographics
NPI:1689987059
Name:DREADFULWATER, SHANNON (LPC)
Entity type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:
Last Name:DREADFULWATER
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:315 N COLLEGE AVE
Mailing Address - Street 2:
Mailing Address - City:TAHLEQUAH
Mailing Address - State:OK
Mailing Address - Zip Code:74464-2703
Mailing Address - Country:US
Mailing Address - Phone:918-453-1171
Mailing Address - Fax:
Practice Address - Street 1:315 N COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74464-2703
Practice Address - Country:US
Practice Address - Phone:918-453-1171
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-14
Last Update Date:2024-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4733101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty