Healthcare Provider Details

I. General information

NPI: 1366247520
Provider Name (Legal Business Name): SHANE LEE MOE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/13/2025
Last Update Date: 06/29/2026
Certification Date: 06/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

618 W MARKET ST
ABERDEEN WA
98520-6016
US

IV. Provider business mailing address

618 W MARKET ST
ABERDEEN WA
98520-6016
US

V. Phone/Fax

Practice location:
  • Phone: 360-219-3933
  • Fax:
Mailing address:
  • Phone: 360-219-3933
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: