Provider Demographics
NPI:1528656246
Name:SPRAGUE, SHAUNA (SUDP-T)
Entity type:Individual
Prefix:
First Name:SHAUNA
Middle Name:
Last Name:SPRAGUE
Suffix:
Gender:F
Credentials:SUDP-T
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:404 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:KELSO
Mailing Address - State:WA
Mailing Address - Zip Code:98626-1118
Mailing Address - Country:US
Mailing Address - Phone:360-423-2806
Mailing Address - Fax:
Practice Address - Street 1:404 W MAIN ST
Practice Address - Street 2:
Practice Address - City:KELSO
Practice Address - State:WA
Practice Address - Zip Code:98626-1118
Practice Address - Country:US
Practice Address - Phone:360-423-2806
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-07
Last Update Date:2021-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACO61105885101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)