=====================================================
General NPI Number Information
=====================================================
NPI Number | 1427965755
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TRICARE INSURANCE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/24/2026
-----------------------------------------------------
Last Update Date | 08/24/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1300 JOHN ADAMS ST STE 104
-----------------------------------------------------
City | OREGON CITY
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97045-1695
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-419-8357
-----------------------------------------------------
Fax | 503-925-3528
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1300 JOHN ADAMS ST STE 104
-----------------------------------------------------
City | OREGON CITY
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97045-1695
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-419-8357
-----------------------------------------------------
Fax | 503-925-3528
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/PRIVATE PRACTICE
-----------------------------------------------------
Name | MRS. SHANNON RENEA GANDER
-----------------------------------------------------
Credential | LMFT
-----------------------------------------------------
Telephone | 503-419-8357
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------