Basic Information
Provider Information | |||||||||
NPI: | 1215584776 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SHIMEK | ||||||||
FirstName: | PATRICIA | ||||||||
MiddleName: | RENEE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MS | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | SHIMEK | ||||||||
OtherFirstName: | RENEE | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | MS | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | 1490 SW 21ST TER | ||||||||
Address2: |   | ||||||||
City: | GRESHAM | ||||||||
State: | OR | ||||||||
PostalCode: | 970806613 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5037302284 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 2222 E POWELL BLVD | ||||||||
Address2: |   | ||||||||
City: | GRESHAM | ||||||||
State: | OR | ||||||||
PostalCode: | 970801365 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5036694300 | ||||||||
FaxNumber: | 5036694301 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/20/2019 | ||||||||
LastUpdateDate: | 08/20/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X |   | OR | Y |   | Behavioral Health & Social Service Providers | Psychologist |   |
No ID Information.