Provider Demographics
NPI:1104078450
Name:HENNINGS, SHELLY NOREEN (CDP, NCAC-I)
Entity type:Individual
Prefix:
First Name:SHELLY
Middle Name:NOREEN
Last Name:HENNINGS
Suffix:
Gender:F
Credentials:CDP, NCAC-I
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2821 MISSION HILL RD
Mailing Address - Street 2:
Mailing Address - City:TULALIP
Mailing Address - State:WA
Mailing Address - Zip Code:98271-9706
Mailing Address - Country:US
Mailing Address - Phone:360-716-4323
Mailing Address - Fax:360-651-4404
Practice Address - Street 1:2821 MISSION HILL RD
Practice Address - Street 2:
Practice Address - City:TULALIP
Practice Address - State:WA
Practice Address - Zip Code:98271-9706
Practice Address - Country:US
Practice Address - Phone:360-716-4323
Practice Address - Fax:360-651-4404
Is Sole Proprietor?:No
Enumeration Date:2008-10-17
Last Update Date:2008-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACP00006202101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WACP00006202OtherDEPARTMENT OF HEALTH