Most Relevant Information
Provider Data
| NPI Number: | 1003634478 |
| Provider Name: | SHANE MICHEAL HARDEMON |
| Entity Type: | Individual |
| Taxonomy Code: | 175T00000X |
| Specialty: | Peer Specialist |
| License Number: |
Most Important Dates
| Enumeration Date: | 10/02/2024 |
| Last Updated: | 10/02/2024 |
Provider Practice Location
444 E COLLEGE AVE
BLACKWELL
OK
746313319
Practice Location Phone/Fax
| Phone: | 5804017527 |
| Fax: |
Provider Mailing Location
444 E COLLEGE AVE
BLACKWELL
OK
746313319
Provider Mailing Phone/Fax
| Phone: | 5804017527 |
| Fax: |