Provider Demographics
NPI:1669758942
Name:ODELL, SHANNON (PSYD)
Entity type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:
Last Name:ODELL
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2545 DELLWOOD DR
Mailing Address - Street 2:
Mailing Address - City:LAKE OSWEGO
Mailing Address - State:OR
Mailing Address - Zip Code:97034-6717
Mailing Address - Country:US
Mailing Address - Phone:360-481-0532
Mailing Address - Fax:
Practice Address - Street 1:530 1ST ST
Practice Address - Street 2:
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97034-3248
Practice Address - Country:US
Practice Address - Phone:503-490-2143
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-31
Last Update Date:2020-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA9442103TC2200X
OR2426103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent