Healthcare Provider Details

I. General information

NPI: 1053884528
Provider Name (Legal Business Name): SHANDRA THEA ROTENBERRY LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/08/2019
Last Update Date: 05/03/2026
Certification Date: 05/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23505 E APPLEWAY AVE STE 200-540
LIBERTY LAKE WA
99019-6065
US

IV. Provider business mailing address

1484 MARION COUNTY 4003
YELLVILLE AR
72687-9343
US

V. Phone/Fax

Practice location:
  • Phone: 253-465-2236
  • Fax:
Mailing address:
  • Phone: 714-356-8077
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLW60854195
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: