Provider Demographics
NPI:1184112922
Name:WHITE, SHANNON ELIZABETH
Entity type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:ELIZABETH
Last Name:WHITE
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 1:257 SW MADISON AVE STE 230
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97333-4924
Mailing Address - Country:US
Mailing Address - Phone:801-560-0424
Mailing Address - Fax:
Practice Address - Street 1:257 SW MADISON AVE STE 230
Practice Address - Street 2:
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97333-4924
Practice Address - Country:US
Practice Address - Phone:801-560-0424
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-26
Last Update Date:2024-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT113907043902106H00000X
ORT1978106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist