Healthcare Provider Details

I. General information

NPI: 1386268381
Provider Name (Legal Business Name): MR. SHAWN DIEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/04/2020
Last Update Date: 12/22/2025
Certification Date: 12/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1170 E CASCADE AVE
SISTERS OR
97759-9009
US

IV. Provider business mailing address

1170 E CASCADE AVE
SISTERS OR
97759-9009
US

V. Phone/Fax

Practice location:
  • Phone: 541-526-1306
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberC7915
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: