Provider Demographics
NPI:1104458645
Name:GANDER, SHANNON RENEA (LMFT-INTERN)
Entity type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:RENEA
Last Name:GANDER
Suffix:
Gender:F
Credentials:LMFT-INTERN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22932 SW WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:SHERWOOD
Mailing Address - State:OR
Mailing Address - Zip Code:97140-7093
Mailing Address - Country:US
Mailing Address - Phone:503-419-8357
Mailing Address - Fax:
Practice Address - Street 1:1300 JOHN ADAMS ST
Practice Address - Street 2:
Practice Address - City:OREGON CITY
Practice Address - State:OR
Practice Address - Zip Code:97045-1695
Practice Address - Country:US
Practice Address - Phone:503-606-8615
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-11
Last Update Date:2020-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORR5780106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist