Basic Information
| Provider Information | |||||||||
| NPI: | 1043386279 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHIEHAN | ||||||||
| FirstName: | MARTIN | ||||||||
| MiddleName: | RAYMOND | ||||||||
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| Credential: | PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2757 FERNDALE DRIVE | ||||||||
| Address2: | |||||||||
| City: | EUGENE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974041870 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5413422110 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 576 OLIVE STREET | ||||||||
| Address2: | |||||||||
| City: | EUGENE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412844616 | ||||||||
| FaxNumber: | 5416866283 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/28/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | Y | Behavioral Health & Social Service Providers | Counselor |
ID Information
| ID | Type | State | Issuer | Description | 037759 | 05 | OR | MEDICAID |