Provider Demographics
NPI:1447521349
Name:DOOLEY, SHANNON
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:DOOLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1406 SW 12TH AVE
Mailing Address - Street 2:APT 6
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97201-8312
Mailing Address - Country:US
Mailing Address - Phone:503-891-8854
Mailing Address - Fax:
Practice Address - Street 1:10313 SW 69TH AVE
Practice Address - Street 2:
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97223-9103
Practice Address - Country:US
Practice Address - Phone:503-726-3696
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-24
Last Update Date:2022-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
OR023375225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health