Provider Demographics
NPI:1114562063
Name:DONOGHUE SHALLOW, MONICA
Entity Type:Individual
Prefix:
First Name:MONICA
Middle Name:
Last Name:DONOGHUE SHALLOW
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17018 15TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:SHORELINE
Mailing Address - State:WA
Mailing Address - Zip Code:98155-5126
Mailing Address - Country:US
Mailing Address - Phone:206-362-7282
Mailing Address - Fax:
Practice Address - Street 1:5204 126TH ST SW
Practice Address - Street 2:
Practice Address - City:MUKILTEO
Practice Address - State:WA
Practice Address - Zip Code:98275-5543
Practice Address - Country:US
Practice Address - Phone:618-979-6112
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-14
Last Update Date:2019-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WASC60809010101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health