Provider Demographics
NPI:1336381565
Name:PERNETTI, SHANNON (ANALYST, MINISTER)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:PERNETTI
Suffix:
Gender:F
Credentials:ANALYST, MINISTER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:407 NE 12TH AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97232
Mailing Address - Country:US
Mailing Address - Phone:503-234-1493
Mailing Address - Fax:503-232-7440
Practice Address - Street 1:407 NE 12TH AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97232
Practice Address - Country:US
Practice Address - Phone:503-234-1493
Practice Address - Fax:503-234-7220
Is Sole Proprietor?:No
Enumeration Date:2009-04-02
Last Update Date:2009-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes102L00000XBehavioral Health & Social Service ProvidersPsychoanalyst