MEDICARE: SHELBY WHITE PSS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	175T00000X	Peer Specialist	112880	OR

General Provider Information

NPI Number	:	1548078074
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHELBY WHITE PSS

Provider Business Mailing Address
First Line	:	1270 PICTURE ST
Second Line	:
City	:	INDEPENDENCE
State	:	OR
Zip	:	97351-9645
Country	:	US
Telephone Number	:	971-901-1020
Fax Number	:

Provider Business Practice Location Address
First Line	:	945 SE UGLOW AVE
Second Line	:
City	:	DALLAS
State	:	OR
Zip	:	97338-2642
Country	:	US
Telephone Number	:	503-837-1762
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/30/2024
Last Update Date	:	12/30/2024

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Directions to “ SHELBY WHITE PSS” Practice Location

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