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General NPI Number Information
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NPI Number | 1669758942
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Entity Type | Individual
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Provider Name | SHANNON ODELL PSYD
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Gender | Female
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Dates
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Enumeration Date | 10/31/2011
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Last Update Date | 02/06/2020
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Provider Practice Location Address
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Address Line | 530 1ST ST
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City | LAKE OSWEGO
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State | OR
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Zip | 97034-3248
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Country | US
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Telephone | 503-490-2143
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Fax |
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Provider Business Mailing Address
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Address Line | 2545 DELLWOOD DR
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City | LAKE OSWEGO
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State | OR
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Zip | 97034-6717
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Country | US
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Telephone | 360-481-0532
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Fax |
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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 | 103TC2200X
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Taxonomy Name | Clinical Child & Adolescent Psychologist
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License Number | 9442
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License Number State | MA
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Taxonomy #2
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Taxonomy Code | 103TC2200X
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Taxonomy Name | Clinical Child & Adolescent Psychologist
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License Number | 2426
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License Number State | OR
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