Healthcare Provider Details

I. General information

NPI: 1164651451
Provider Name (Legal Business Name): PETER THOMPSON SHANNON M.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/08/2009
Last Update Date: 07/08/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 HIGH ST SUITE B
EUGENE OR
97401-4192
US

IV. Provider business mailing address

1400 HIGH ST SUITE B
EUGENE OR
97401-4192
US

V. Phone/Fax

Practice location:
  • Phone: 541-683-8438
  • Fax: 541-485-2059
Mailing address:
  • Phone: 541-683-8438
  • Fax: 541-485-2059

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC#CO132
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: