Provider Demographics
NPI:1588170369
Name:SHADLE, KRISTEN LEE (LMFT)
Entity type:Individual
Prefix:
First Name:KRISTEN
Middle Name:LEE
Last Name:SHADLE
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:KRISTEN
Other - Middle Name:LEE
Other - Last Name:GRAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:336 NE NORTON AVE STE 1
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97701-4386
Mailing Address - Country:US
Mailing Address - Phone:541-622-2533
Mailing Address - Fax:
Practice Address - Street 1:336 NE NORTON AVE STE 1
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-4386
Practice Address - Country:US
Practice Address - Phone:541-622-2533
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-16
Last Update Date:2022-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA100648106H00000X
ORT1875106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist