Provider Demographics
NPI:1255832317
Name:GISH, SHASTA (CADC I)
Entity Type:Individual
Prefix:
First Name:SHASTA
Middle Name:
Last Name:GISH
Suffix:
Gender:F
Credentials:CADC I
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:221 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97501-2728
Mailing Address - Country:US
Mailing Address - Phone:541-772-1777
Mailing Address - Fax:
Practice Address - Street 1:221 W MAIN ST
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97501
Practice Address - Country:US
Practice Address - Phone:541-772-1777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-23
Last Update Date:2018-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor