Healthcare Provider Details

I. General information

NPI: 1114172285
Provider Name (Legal Business Name): SHAYNA CARTER MA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/17/2008
Last Update Date: 11/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1217 NE BURNSIDE RD BUILDING B, SUITE 401
GRESHAM OR
97030-6722
US

IV. Provider business mailing address

PO BOX 82819
PORTLAND OR
97282-0819
US

V. Phone/Fax

Practice location:
  • Phone: 503-666-8832
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number060305
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberC2072
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier164936
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: