Provider Demographics
NPI:1043428386
Name:SHELLMIRE, RAY A (LCSW)
Entity Type:Individual
Prefix:
First Name:RAY
Middle Name:A
Last Name:SHELLMIRE
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:872 NE 166TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97230-6164
Mailing Address - Country:US
Mailing Address - Phone:503-288-2767
Mailing Address - Fax:503-288-2767
Practice Address - Street 1:4134 N VANCOUVER AVE
Practice Address - Street 2:SUITE 102
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97217-2900
Practice Address - Country:US
Practice Address - Phone:503-331-2548
Practice Address - Fax:503-331-2549
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2376101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR167863 SCOtherOMAP