Provider Demographics
NPI:1467941831
Name:MADORE, SHANNON (PHD)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:MADORE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:M
Other - Last Name:NUGENT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHD
Mailing Address - Street 1:160 SW 90TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97225-6810
Mailing Address - Country:US
Mailing Address - Phone:970-389-5604
Mailing Address - Fax:
Practice Address - Street 1:3710 SW US VETERANS HOSPITAL RD # R&D66
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-2964
Practice Address - Country:US
Practice Address - Phone:503-220-8262
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-01
Last Update Date:2018-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2896103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical