Provider Demographics
NPI:1922085307
Name:IVERSON, SHAWNA DEANNE (MOT OTR L)
Entity Type:Individual
Prefix:MRS
First Name:SHAWNA
Middle Name:DEANNE
Last Name:IVERSON
Suffix:
Gender:F
Credentials:MOT OTR L
Other - Prefix:
Other - First Name:SHAWNA
Other - Middle Name:DEANNE
Other - Last Name:WALLACE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1402 GWINN ST E
Mailing Address - Street 2:
Mailing Address - City:MONMOUTH
Mailing Address - State:OR
Mailing Address - Zip Code:97361
Mailing Address - Country:US
Mailing Address - Phone:503-510-5814
Mailing Address - Fax:
Practice Address - Street 1:290 MOYER LN NW
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97304
Practice Address - Country:US
Practice Address - Phone:503-370-8990
Practice Address - Fax:503-363-4214
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1053130225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR276082Medicaid