Healthcare Provider Details

I. General information

NPI: 1629634431
Provider Name (Legal Business Name): SHALAINE JOY MISTRETTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/16/2019
Last Update Date: 07/21/2026
Certification Date: 07/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20500 SE HIGHWAY 212
DAMASCUS OR
97089-7254
US

IV. Provider business mailing address

28980 SE K W ANDERSON RD
GRESHAM OR
97080-0019
US

V. Phone/Fax

Practice location:
  • Phone: 503-433-3996
  • Fax:
Mailing address:
  • Phone: 503-880-0136
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberL7632
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: