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General NPI Number Information
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NPI Number | 1215289210
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Entity Type | Individual
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Provider Name | SHANNON NICOLE FARROUGE M.A, LPC
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Gender | Female
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Dates
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Enumeration Date | 10/15/2012
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Last Update Date | 02/19/2019
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Provider Practice Location Address
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Address Line | 5520 SW MACADAM, AVE SUITE 270
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City | PORTLAND
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State | OR
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Zip | 97239
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Country | US
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Telephone | 503-888-1369
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Fax | 503-646-8401
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Provider Business Mailing Address
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Address Line | 5520 SW MACADAM, AVE SUITE 270
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City | PORTLAND
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State | OR
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Zip | 97239
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Country | US
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Telephone | 503-888-1369
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Fax | 503-646-8401
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101Y00000X
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Taxonomy Name | Counselor
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | C3859
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License Number State | OR
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Taxonomy #3
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Taxonomy Code | 101Y00000X
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Taxonomy Name | Counselor
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License Number | C3859
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License Number State | OR
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