Provider Demographics
NPI:1043048986
Name:SHAW, TRA'VANT'E KEAGON
Entity type:Individual
Prefix:
First Name:TRA'VANT'E
Middle Name:KEAGON
Last Name:SHAW
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 W DAVIS AVE APT 15
Mailing Address - Street 2:
Mailing Address - City:WEATHERFORD
Mailing Address - State:OK
Mailing Address - Zip Code:73096-3016
Mailing Address - Country:US
Mailing Address - Phone:580-279-7852
Mailing Address - Fax:
Practice Address - Street 1:401 S COLTRANE RD STE 260
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73034-6722
Practice Address - Country:US
Practice Address - Phone:405-465-6607
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-23
Last Update Date:2024-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1165994106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician