Healthcare Provider Details

I. General information

NPI: 1245885250
Provider Name (Legal Business Name): SHASTA HICKMAN-SUPPES LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/06/2019
Last Update Date: 07/08/2026
Certification Date: 07/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 BROADWAY ST NE STE 206
SALEM OR
97301-0504
US

IV. Provider business mailing address

1400 BROADWAY ST NE STE 206
SALEM OR
97301-0504
US

V. Phone/Fax

Practice location:
  • Phone: 971-303-9868
  • Fax:
Mailing address:
  • Phone: 971-303-9868
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLH61102916
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberC6107
License Number StateOR
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMC60943341
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: