Provider Demographics
NPI:1114708039
Name:SHROCK RUSSELL, RACHEL JUNE
Entity Type:Individual
Prefix:
First Name:RACHEL
Middle Name:JUNE
Last Name:SHROCK RUSSELL
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 1:1970 MADRAS ST SE APT 2088
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97306-2394
Mailing Address - Country:US
Mailing Address - Phone:503-979-3352
Mailing Address - Fax:
Practice Address - Street 1:435 NE EVANS ST STE A
Practice Address - Street 2:
Practice Address - City:MCMINNVILLE
Practice Address - State:OR
Practice Address - Zip Code:97128-4635
Practice Address - Country:US
Practice Address - Phone:503-472-4020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-06
Last Update Date:2023-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health