Healthcare Provider Details

I. General information

NPI: 1750511408
Provider Name (Legal Business Name): SHANNON KELLIM YOUNG LP, LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/15/2009
Last Update Date: 11/13/2024
Certification Date: 11/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1210 PEARL ST
EUGENE OR
97401-3573
US

IV. Provider business mailing address

1210 PEARL ST
EUGENE OR
97401-3573
US

V. Phone/Fax

Practice location:
  • Phone: 541-344-5440
  • Fax:
Mailing address:
  • Phone: 541-344-5440
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number4454
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number2298
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: