MEDICARE: SHANE WILLIAM OOSTINGA

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	101YA0400X	Addiction (Substance Use Disorder) Counselor
2	175T00000X	Peer Specialist

General Provider Information

NPI Number	:	1629802087
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHANE WILLIAM OOSTINGA

Provider Business Mailing Address
First Line	:	1076 SANTO ANTONIO DR
Second Line	:
City	:	COLTON
State	:	CA
Zip	:	92324-8103
Country	:	US
Telephone Number	:	909-433-9824
Fax Number	:

Provider Business Practice Location Address
First Line	:	1076 SANTO ANTONIO DR
Second Line	:
City	:	COLTON
State	:	CA
Zip	:	92324-8103
Country	:	US
Telephone Number	:	909-433-9824
Fax Number	:

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

Provider Enumeration Date	:	08/28/2024
Last Update Date	:	03/06/2026

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