Basic Information
| Provider Information | |||||||||
| NPI: | 1831739796 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WATERS | ||||||||
| FirstName: | SHANNON | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | C6686 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2555 PACIFIC BLVD | ||||||||
| Address2: | |||||||||
| City: | ALBANY | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973211841 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5413212278 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2440 WILLAMETTE ST STE 201 | ||||||||
| Address2: | |||||||||
| City: | EUGENE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974053170 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5413212278 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/08/2020 | ||||||||
| LastUpdateDate: | 08/30/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/30/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | C6686 | OR | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 500775892 | 05 | OR | MEDICAID |