Provider Demographics
NPI:1295562510
Name:OTTRE, SHELLY RAE (LPC)
Entity type:Individual
Prefix:
First Name:SHELLY
Middle Name:RAE
Last Name:OTTRE
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30077 INGRAM RD
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:OR
Mailing Address - Zip Code:97355-9506
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:880 S MAIN ST
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:OR
Practice Address - Zip Code:97355-3210
Practice Address - Country:US
Practice Address - Phone:541-933-5730
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-19
Last Update Date:2024-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC8833101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional