Provider Demographics
NPI:1316469596
Name:SHULTZ, SHAWN E (BSW, CADC I, QMHA)
Entity type:Individual
Prefix:
First Name:SHAWN
Middle Name:E
Last Name:SHULTZ
Suffix:
Gender:M
Credentials:BSW, CADC I, QMHA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12662 SE STARK ST STE A
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97233-1058
Mailing Address - Country:US
Mailing Address - Phone:503-546-7677
Mailing Address - Fax:
Practice Address - Street 1:12662 SE STARK ST STE A
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97233-1058
Practice Address - Country:US
Practice Address - Phone:503-546-7677
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-10
Last Update Date:2023-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR1316469596Medicaid