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General NPI Number Information
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NPI Number | 1316254022
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Entity Type | Individual
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Provider Name | SHANAKO DEVOLL CADC I, QMHA
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Gender | Female
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Dates
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Enumeration Date | 09/02/2010
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Last Update Date | 04/27/2023
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Provider Practice Location Address
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Address Line | 2450 SE BELMONT ST
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City | PORTLAND
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State | OR
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Zip | 97214-2821
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Country | US
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Telephone | 503-887-6255
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Fax | 503-212-0969
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Provider Business Mailing Address
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Address Line | 232 NW 6TH AVE
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City | PORTLAND
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State | OR
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Zip | 97209-3609
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Country | US
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Telephone | 503-200-3923
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Fax | 503-241-7419
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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 | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | 05-03-01
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License Number State | OR
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Taxonomy #2
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Taxonomy Code | 171M00000X
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Taxonomy Name | Case Manager/Care Coordinator
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | L7423
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License Number State | OR
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