Basic Information
| Provider Information | |||||||||
| NPI: | 1134590730 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FERRY BRANAUGH | ||||||||
| FirstName: | SHANNON | ||||||||
| MiddleName: | E. | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 541 WILLAMETTE ST STE 407A | ||||||||
| Address2: | |||||||||
| City: | EUGENE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974012696 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412090289 | ||||||||
| FaxNumber: | 9999999999 | ||||||||
| Practice Location | |||||||||
| Address1: | 541 WILLAMETTE ST STE 407A | ||||||||
| Address2: | |||||||||
| City: | EUGENE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974012696 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412090289 | ||||||||
| FaxNumber: | 9999999999 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/08/2015 | ||||||||
| LastUpdateDate: | 04/29/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 04/29/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 104100000X | OR | N | Behavioral Health & Social Service Providers | Social Worker | 1041C0700X | L10532 | OR | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | L10532 | 01 | OR | LCSW LICENSE | OTHER |