Provider Demographics
NPI:1942637947
Name:SHEA, SAMUEL (MS CHP)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:
Last Name:SHEA
Suffix:
Gender:M
Credentials:MS CHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4125 N LONGVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97217-3354
Mailing Address - Country:US
Mailing Address - Phone:503-244-4456
Mailing Address - Fax:
Practice Address - Street 1:825 NE 20TH AVE STE 330
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97232-1000
Practice Address - Country:US
Practice Address - Phone:503-290-1916
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-10-04
Last Update Date:2013-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker