Provider Demographics
NPI:1447840301
Name:DALLEY, SHANNON MARIE (PSYD)
Entity type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:MARIE
Last Name:DALLEY
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15935 SW 146TH AVE
Mailing Address - Street 2:
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97224-1380
Mailing Address - Country:US
Mailing Address - Phone:978-996-9521
Mailing Address - Fax:
Practice Address - Street 1:15935 SW 146TH AVE
Practice Address - Street 2:
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97224-1380
Practice Address - Country:US
Practice Address - Phone:360-602-2563
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-24
Last Update Date:2024-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPY61053793103TC0700X
OR3620103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical