1558607994 NPI number — MR. BRADLEY ROE SHUMATE M.S, M.A., LMHC

Table of content: MR. BRADLEY ROE SHUMATE M.S, M.A., LMHC (NPI 1558607994)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558607994 NPI number — MR. BRADLEY ROE SHUMATE M.S, M.A., LMHC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHUMATE
Provider First Name:
BRADLEY
Provider Middle Name:
ROE
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
M.S, M.A., LMHC
Provider Gender Code:
M

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:
1558607994
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/30/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7507 NE 51ST ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VANCOUVER
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98662-6007
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-906-1190
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1200 HILYARD ST STE 420
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EUGENE
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97401-8161
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
458-205-6444
Provider Business Practice Location Address Fax Number:
458-205-6440
Provider Enumeration Date:
12/12/2012

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: 101YP2500X , with the licence number:  C3790 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 101YM0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





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