Healthcare Provider Details

I. General information

NPI: 1326216938
Provider Name (Legal Business Name): SHEA O'DONNELL ROOT M.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/16/2008
Last Update Date: 05/21/2020
Certification Date: 05/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9123 SE SAINT HELENS ST STE 270B
CLACKAMAS OR
97015-6801
US

IV. Provider business mailing address

4612 SE 32ND AVE
PORTLAND OR
97202-3406
US

V. Phone/Fax

Practice location:
  • Phone: 855-583-3842
  • Fax:
Mailing address:
  • Phone: 503-236-0424
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberC4840
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: