Healthcare Provider Details

I. General information

NPI: 1396491510
Provider Name (Legal Business Name): SHAWN GARY DEWALL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/25/2022
Last Update Date: 09/22/2026
Certification Date: 09/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3415 SE POWELL BLVD
PORTLAND OR
97202-3371
US

IV. Provider business mailing address

3415 SE POWELL BLVD
PORTLAND OR
97202-3371
US

V. Phone/Fax

Practice location:
  • Phone: 503-980-8142
  • Fax:
Mailing address:
  • Phone: 503-980-8142
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberC10277
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: