Provider Demographics
NPI:1710672449
Name:SMEDLEY, SHANE (QMHA-R, CRM, PSS-AD)
Entity Type:Individual
Prefix:MR
First Name:SHANE
Middle Name:
Last Name:SMEDLEY
Suffix:
Gender:M
Credentials:QMHA-R, CRM, PSS-AD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:361 YEWWOOD DR
Mailing Address - Street 2:
Mailing Address - City:SHADY COVE
Mailing Address - State:OR
Mailing Address - Zip Code:97539-9794
Mailing Address - Country:US
Mailing Address - Phone:458-204-8226
Mailing Address - Fax:
Practice Address - Street 1:361 YEWWOOD DR
Practice Address - Street 2:
Practice Address - City:SHADY COVE
Practice Address - State:OR
Practice Address - Zip Code:97539-9794
Practice Address - Country:US
Practice Address - Phone:458-204-8226
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-10
Last Update Date:2023-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR108144175T00000X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No175T00000XOther Service ProvidersPeer Specialist