Provider Demographics
NPI:1962979724
Name:SKINNER, SHANE ANDREW SR (CDP)
Entity type:Individual
Prefix:MR
First Name:SHANE
Middle Name:ANDREW
Last Name:SKINNER
Suffix:SR
Gender:M
Credentials:CDP
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:360-423-2806
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:360-423-2806
Is Sole Proprietor?:No
Enumeration Date:2018-10-30
Last Update Date:2018-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACP60688887101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)