Provider Demographics
NPI:1770253387
Name:SHAW, CANDACE LYNN
Entity Type:Individual
Prefix:
First Name:CANDACE
Middle Name:LYNN
Last Name:SHAW
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:185 N 4TH ST
Mailing Address - Street 2:
Mailing Address - City:SAINT HELENS
Mailing Address - State:OR
Mailing Address - Zip Code:97051-1535
Mailing Address - Country:US
Mailing Address - Phone:503-438-2180
Mailing Address - Fax:503-366-4526
Practice Address - Street 1:185 N 4TH ST
Practice Address - Street 2:
Practice Address - City:SAINT HELENS
Practice Address - State:OR
Practice Address - Zip Code:97051-1535
Practice Address - Country:US
Practice Address - Phone:503-438-2180
Practice Address - Fax:503-366-4526
Is Sole Proprietor?:No
Enumeration Date:2021-09-15
Last Update Date:2021-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
132700000X
ORQMHA-1644101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No132700000XDietary & Nutritional Service ProvidersDietary Manager
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR1770253387OtherMENTAL HEALTH CLINICIAN