Basic Information
| Provider Information | |||||||||
| NPI: | 1215289210 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FARROUGE | ||||||||
| FirstName: | SHANNON | ||||||||
| MiddleName: | NICOLE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.A, LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5520 SW MACADAM, AVE | ||||||||
| Address2: | SUITE 270 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97239 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5038881369 | ||||||||
| FaxNumber: | 5036468401 | ||||||||
| Practice Location | |||||||||
| Address1: | 5520 SW MACADAM, AVE | ||||||||
| Address2: | SUITE 270 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97239 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5038881369 | ||||||||
| FaxNumber: | 5036468401 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/15/2012 | ||||||||
| LastUpdateDate: | 02/19/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | N | Behavioral Health & Social Service Providers | Counselor | 101YP2500X | C3859 | OR | N | Behavioral Health & Social Service Providers | Counselor | Professional | 101Y00000X | C3859 | OR | Y | Behavioral Health & Social Service Providers | Counselor |
ID Information
| ID | Type | State | Issuer | Description | 0000WDBCH | 01 | WA | GROUP MEDICARE | OTHER | 164936 | 05 | OR | MEDICAID | 0000WDBCH | 01 | OR | GROUP MEDICARE | OTHER |