1215289210 NPI number — MRS. SHANNON NICOLE FARROUGE M.A, LPC

Table of content: MRS. SHANNON NICOLE FARROUGE M.A, LPC (NPI 1215289210)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215289210 NPI number — MRS. SHANNON NICOLE FARROUGE M.A, LPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FARROUGE
Provider First Name:
SHANNON
Provider Middle Name:
NICOLE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
M.A, LPC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1215289210
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/19/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5520 SW MACADAM, AVE
Provider Second Line Business Mailing Address:
SUITE 270
Provider Business Mailing Address City Name:
PORTLAND
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97239
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-888-1369
Provider Business Mailing Address Fax Number:
503-646-8401

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5520 SW MACADAM, AVE
Provider Second Line Business Practice Location Address:
SUITE 270
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97239
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-888-1369
Provider Business Practice Location Address Fax Number:
503-646-8401
Provider Enumeration Date:
10/15/2012

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101Y00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YP2500X , with the licence number: C3859 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101Y00000X , with the licence number: C3859 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0000WDBCH . This is a "GROUP MEDICARE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 164936 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0000WDBCH . This is a "GROUP MEDICARE" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".




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