Provider Demographics
NPI:1124524822
Name:STRUTHERS, SHANE SCOTT
Entity type:Individual
Prefix:
First Name:SHANE
Middle Name:SCOTT
Last Name:STRUTHERS
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 1:7801 47TH AVE NE UNIT A202
Mailing Address - Street 2:
Mailing Address - City:MARYSVILLE
Mailing Address - State:WA
Mailing Address - Zip Code:98270-3828
Mailing Address - Country:US
Mailing Address - Phone:505-688-9216
Mailing Address - Fax:
Practice Address - Street 1:6505 218TH ST SW STE 9
Practice Address - Street 2:
Practice Address - City:MOUNTLAKE TERRACE
Practice Address - State:WA
Practice Address - Zip Code:98043-2135
Practice Address - Country:US
Practice Address - Phone:206-388-0544
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-02
Last Update Date:2018-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst