Healthcare Provider Details

I. General information

NPI: 1457540809
Provider Name (Legal Business Name): ALLISON ANN SHADDAY LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/22/2007
Last Update Date: 02/16/2023
Certification Date: 02/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

61558 DEVILS LAKE DRIVE
BEND OR
97702-9150
US

IV. Provider business mailing address

61558 DEVILS LAKE DRIVE
BEND OR
97702-9150
US

V. Phone/Fax

Practice location:
  • Phone: 808-469-7623
  • Fax: 808-263-3655
Mailing address:
  • Phone: 808-469-7623
  • Fax: 808-263-3655

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLW00008141
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number10752
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: