Provider Demographics
NPI:1851410070
Name:HAVENS, SHALENA DAWN (LAC)
Entity Type:Individual
Prefix:
First Name:SHALENA
Middle Name:DAWN
Last Name:HAVENS
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2025 SE JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKIE
Mailing Address - State:OR
Mailing Address - Zip Code:97222-7605
Mailing Address - Country:US
Mailing Address - Phone:503-886-9708
Mailing Address - Fax:
Practice Address - Street 1:2025 SE JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:MILWAUKIE
Practice Address - State:OR
Practice Address - Zip Code:97222-7605
Practice Address - Country:US
Practice Address - Phone:503-886-9708
Practice Address - Fax:503-905-6164
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-28
Last Update Date:2016-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAC 000917171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500676532OtherDMAP