Provider Demographics
NPI:1194102111
Name:MATSON, SHANNON (CADC I)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:MATSON
Suffix:
Gender:F
Credentials:CADC I
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 SW C ST
Mailing Address - Street 2:
Mailing Address - City:MADRAS
Mailing Address - State:OR
Mailing Address - Zip Code:97741-1458
Mailing Address - Country:US
Mailing Address - Phone:541-475-6575
Mailing Address - Fax:541-504-1195
Practice Address - Street 1:125 SW C ST
Practice Address - Street 2:
Practice Address - City:MADRAS
Practice Address - State:OR
Practice Address - Zip Code:97741-1458
Practice Address - Country:US
Practice Address - Phone:541-475-6575
Practice Address - Fax:541-504-1195
Is Sole Proprietor?:No
Enumeration Date:2015-04-28
Last Update Date:2015-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR15-01-07101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)