Provider Demographics
NPI:1730654237
Name:CUSHNER, SHELLANY JEAN (LCSW)
Entity Type:Individual
Prefix:
First Name:SHELLANY
Middle Name:JEAN
Last Name:CUSHNER
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:SANTIAM HWY
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:OR
Mailing Address - Zip Code:97355-9511
Mailing Address - Country:US
Mailing Address - Phone:541-967-3866
Mailing Address - Fax:
Practice Address - Street 1:1600 S MAIN ST
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:OR
Practice Address - Zip Code:97355-3109
Practice Address - Country:US
Practice Address - Phone:541-967-3866
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-10
Last Update Date:2018-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL76981041C0700X
L76981041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR$$$$$$$$$Medicaid