Provider Demographics
NPI:1841636297
Name:BALUE, SHANNON ELIZABETH (LMT)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:ELIZABETH
Last Name:BALUE
Suffix:
Gender:
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:628 NE ROSELAWN ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97211-3830
Mailing Address - Country:US
Mailing Address - Phone:323-371-4829
Mailing Address - Fax:
Practice Address - Street 1:5924 ANAHEIM AVE NE STE B
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87113-1879
Practice Address - Country:US
Practice Address - Phone:505-881-4618
Practice Address - Fax:505-922-4917
Is Sole Proprietor?:No
Enumeration Date:2013-05-13
Last Update Date:2025-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR19720225700000X
235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist