Healthcare Provider Details

I. General information

NPI: 1902245145
Provider Name (Legal Business Name): MICHELLE LOUISE SHAWVER PSY.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/20/2013
Last Update Date: 04/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

45 NW PARK PL
BEND OR
97703-2954
US

IV. Provider business mailing address

45 NW PARK PL
BEND OR
97703-2954
US

V. Phone/Fax

Practice location:
  • Phone: 541-508-7746
  • Fax:
Mailing address:
  • Phone: 541-508-7746
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number2158
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number2158
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: