Provider Demographics
NPI:1114137494
Name:SHADE, GLADYS (QMHP, LCSW)
Entity Type:Individual
Prefix:MS
First Name:GLADYS
Middle Name:
Last Name:SHADE
Suffix:
Gender:F
Credentials:QMHP, LCSW
Other - Prefix:MS
Other - First Name:ALEX
Other - Middle Name:
Other - Last Name:SHADE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:1890 WAITE ST
Mailing Address - Street 2:SUITE 1
Mailing Address - City:NORTH BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97459-1229
Mailing Address - Country:US
Mailing Address - Phone:541-756-6232
Mailing Address - Fax:541-756-6234
Practice Address - Street 1:1890 WAITE ST
Practice Address - Street 2:SUITE 1
Practice Address - City:NORTH BEND
Practice Address - State:OR
Practice Address - Zip Code:97459-1229
Practice Address - Country:US
Practice Address - Phone:541-756-6232
Practice Address - Fax:541-756-6234
Is Sole Proprietor?:No
Enumeration Date:2007-05-23
Last Update Date:2008-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR31241041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR142063OtherMEDICARE PTAN
OR1619915113OtherGROUP NUMBER NPI
R120353OtherPTAN
OR213342Medicaid
R120353OtherPTAN