Healthcare Provider Details

I. General information

NPI: 1174449201
Provider Name (Legal Business Name): TRAVIS SHADDY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2026
Last Update Date: 06/24/2026
Certification Date: 06/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 SERENITY LN
COBURG OR
97408-9350
US

IV. Provider business mailing address

1 SERENITY LN
COBURG OR
97408-9350
US

V. Phone/Fax

Practice location:
  • Phone: 541-687-1110
  • Fax:
Mailing address:
  • Phone: 541-687-1110
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberT-25-6129
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: