Provider Demographics
NPI:1881121911
Name:RETTLER, SHAMUS MICHEAL
Entity type:Individual
Prefix:MR
First Name:SHAMUS
Middle Name:MICHEAL
Last Name:RETTLER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 NE MARTIN LUTHER KING BLVD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97232-2941
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:30 NE MARTIN LUTHER KING BLVD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97232-2941
Practice Address - Country:US
Practice Address - Phone:503-232-1099
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-19
Last Update Date:2021-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician