Provider Demographics
NPI:1629612411
Name:STRONACH, SHANNON MARIE (PEER SUPPORT)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:MARIE
Last Name:STRONACH
Suffix:
Gender:F
Credentials:PEER SUPPORT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4101 NE DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:GRESHAM
Mailing Address - State:OR
Mailing Address - Zip Code:97030-4617
Mailing Address - Country:US
Mailing Address - Phone:503-666-6575
Mailing Address - Fax:
Practice Address - Street 1:805 SE 151ST AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97233-2916
Practice Address - Country:US
Practice Address - Phone:971-217-7040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-05
Last Update Date:2019-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist