Provider Demographics
NPI:1083181648
Name:CANTRELL, SHANNON RAE (CDPT)
Entity Type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:RAE
Last Name:CANTRELL
Suffix:
Gender:F
Credentials:CDPT
Other - Prefix:MISS
Other - First Name:SHANNON
Other - Middle Name:RAE
Other - Last Name:BARKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CDPT
Mailing Address - Street 1:19351 8TH AVE NE STE 141
Mailing Address - Street 2:
Mailing Address - City:POULSBO
Mailing Address - State:WA
Mailing Address - Zip Code:98370-7087
Mailing Address - Country:US
Mailing Address - Phone:360-876-9430
Mailing Address - Fax:360-598-4114
Practice Address - Street 1:19351 8TH AVE NE STE 141
Practice Address - Street 2:
Practice Address - City:POULSBO
Practice Address - State:WA
Practice Address - Zip Code:98370-7087
Practice Address - Country:US
Practice Address - Phone:360-876-9430
Practice Address - Fax:360-598-4114
Is Sole Proprietor?:No
Enumeration Date:2018-10-31
Last Update Date:2018-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACO60724206101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)