Healthcare Provider Details

I. General information

NPI: 1770253387
Provider Name (Legal Business Name): CANDACE LYNN SHAW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2021
Last Update Date: 10/12/2021
Certification Date: 10/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

185 N 4TH ST
SAINT HELENS OR
97051-1535
US

IV. Provider business mailing address

185 N 4TH ST
SAINT HELENS OR
97051-1535
US

V. Phone/Fax

Practice location:
  • Phone: 503-438-2180
  • Fax: 503-366-4526
Mailing address:
  • Phone: 503-438-2180
  • Fax: 503-366-4526

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code132700000X
TaxonomyDietary Manager
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberQMHA-1644
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: