Provider Demographics
NPI:1528597382
Name:PUGERUDE, SHANNON KATHLEEN (MS, QMHP)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:KATHLEEN
Last Name:PUGERUDE
Suffix:
Gender:F
Credentials:MS, QMHP
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:KATHLEEN
Other - Last Name:STEVENSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS
Mailing Address - Street 1:3995 MARCOLA RD
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OR
Mailing Address - Zip Code:97477-7948
Mailing Address - Country:US
Mailing Address - Phone:541-726-1465
Mailing Address - Fax:541-726-5085
Practice Address - Street 1:1195 NW WALL ST
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97703-1965
Practice Address - Country:US
Practice Address - Phone:541-728-0062
Practice Address - Fax:541-306-6733
Is Sole Proprietor?:No
Enumeration Date:2017-06-06
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health