Basic Information
| Provider Information | |||||||||
| NPI: | 1457478331 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCDANIEL | ||||||||
| FirstName: | SHANE | ||||||||
| MiddleName: | STEPHEN | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MSW, CSWA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 182 SW ACADEMY ST | ||||||||
| Address2: | SUITE 304 | ||||||||
| City: | DALLAS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973381922 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5036231886 | ||||||||
| FaxNumber: | 5036237560 | ||||||||
| Practice Location | |||||||||
| Address1: | 182 SW ACADEMY ST | ||||||||
| Address2: | SUITE 304 | ||||||||
| City: | DALLAS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973381922 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5036231886 | ||||||||
| FaxNumber: | 5036237560 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/23/2007 | ||||||||
| LastUpdateDate: | 04/16/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | N | Other Service Providers | Case Manager/Care Coordinator | 104100000X | A3638 | OR | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.