Healthcare Provider Details

I. General information

NPI: 1851410070
Provider Name (Legal Business Name): SHALENA DAWN HAVENS LAC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/28/2007
Last Update Date: 12/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2025 SE JEFFERSON ST
MILWAUKIE OR
97222-7605
US

IV. Provider business mailing address

2025 SE JEFFERSON ST
MILWAUKIE OR
97222-7605
US

V. Phone/Fax

Practice location:
  • Phone: 503-886-9708
  • Fax: 503-905-6164
Mailing address:
  • Phone: 503-886-9708
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC 000917
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: