=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245605666
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KATHLEEN SHIPLEY MA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/10/2015
-----------------------------------------------------
Last Update Date | 04/05/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 377 SW CENTURY DR STE 208
-----------------------------------------------------
City | BEND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97702-1419
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-897-7545
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 377 SW CENTURY DR STE 208
-----------------------------------------------------
City | BEND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97702-1419
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | 90423
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | T1418
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------