Basic Information
| Provider Information | |||||||||
| NPI: | 1114172285 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CARTER | ||||||||
| FirstName: | SHAYNA | ||||||||
| MiddleName: | |||||||||
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| Credential: | MA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 82819 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972820819 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1217 NE BURNSIDE RD | ||||||||
| Address2: | BUILDING B, SUITE 401 | ||||||||
| City: | GRESHAM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970306722 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5036668832 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/17/2008 | ||||||||
| LastUpdateDate: | 11/17/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 060305 | OR | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YP2500X | C2072 | OR | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 164936 | 05 | OR | MEDICAID |