Provider Demographics
NPI:1124426093
Name:SHEWELL, SKIP
Entity type:Individual
Prefix:
First Name:SKIP
Middle Name:
Last Name:SHEWELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:631 NE 102ND AVE STE 104
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97220-4004
Mailing Address - Country:US
Mailing Address - Phone:510-289-3412
Mailing Address - Fax:
Practice Address - Street 1:631 NE 102ND AVE STE 104
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97220-4004
Practice Address - Country:US
Practice Address - Phone:510-289-3412
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-09
Last Update Date:2022-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC3820101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty