Healthcare Provider Details

I. General information

NPI: 1669949640
Provider Name (Legal Business Name): SHANNA MARIE PICKENS CDAC II
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/29/2018
Last Update Date: 06/24/2026
Certification Date: 06/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1217 NE BURNSIDE RD STE 701
GRESHAM OR
97030-5770
US

IV. Provider business mailing address

1217 NE BURNSIDE RD STE 701
GRESHAM OR
97030-5770
US

V. Phone/Fax

Practice location:
  • Phone: 503-760-6449
  • Fax:
Mailing address:
  • Phone: 503-760-6449
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number26-R-16
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: