Provider Demographics
NPI:1215289210
Name:FARROUGE, SHANNON NICOLE (MA, LPC)
Entity type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:NICOLE
Last Name:FARROUGE
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5520 SW MACADAM, AVE
Mailing Address - Street 2:SUITE 270
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239
Mailing Address - Country:US
Mailing Address - Phone:503-888-1369
Mailing Address - Fax:503-646-8401
Practice Address - Street 1:5520 SW MACADAM, AVE
Practice Address - Street 2:SUITE 270
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239
Practice Address - Country:US
Practice Address - Phone:503-888-1369
Practice Address - Fax:503-646-8401
Is Sole Proprietor?:No
Enumeration Date:2012-10-15
Last Update Date:2019-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
ORC3859101YP2500X, 101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0000WDBCHOtherGROUP MEDICARE
OR164936Medicaid
OR0000WDBCHOtherGROUP MEDICARE