MEDICARE: SHYN A CHILDRESS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	22995	OR
2	101YM0800X	Mental Health Counselor

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1205494069
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHYN A CHILDRESS

Provider Business Mailing Address
First Line	:	4556 14TH CT S
Second Line	:
City	:	SALEM
State	:	OR
Zip	:	97302-2305
Country	:	US
Telephone Number	:	503-400-5744
Fax Number	:

Provider Business Practice Location Address
First Line	:	2110 STATE ST STE 202
Second Line	:
City	:	SALEM
State	:	OR
Zip	:	97301-4350
Country	:	US
Telephone Number	:	503-580-9819
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/05/2019
Last Update Date	:	08/05/2019

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Directions to “ SHYN A CHILDRESS ” Practice Location

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