Provider Demographics
NPI:1326151895
Name:SHANAHE, MARIAROSE M (LCSW)
Entity Type:Individual
Prefix:
First Name:MARIAROSE
Middle Name:M
Last Name:SHANAHE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1010 1ST ST SE
Mailing Address - Street 2:SUITE 265
Mailing Address - City:BANDON
Mailing Address - State:OR
Mailing Address - Zip Code:97411-9301
Mailing Address - Country:US
Mailing Address - Phone:541-329-0110
Mailing Address - Fax:
Practice Address - Street 1:1010 1ST ST SE
Practice Address - Street 2:SUITE 265
Practice Address - City:BANDON
Practice Address - State:OR
Practice Address - Zip Code:97411-9301
Practice Address - Country:US
Practice Address - Phone:541-329-0110
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-17
Last Update Date:2009-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL4547101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health