Basic Information
| Provider Information | |||||||||
| NPI: | 1295846483 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CRISWELL | ||||||||
| FirstName: | SHAWN | ||||||||
| MiddleName: | |||||||||
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| Credential: | LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5940 ULALI DR NE | ||||||||
| Address2: | |||||||||
| City: | KEIZER | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973031500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5038132000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5940 ULALI DR NE | ||||||||
| Address2: | |||||||||
| City: | KEIZER | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973031500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5038132000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2006 | ||||||||
| LastUpdateDate: | 12/29/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/29/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | LH00005103 | WA | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YM0800X | C1079 | OR | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.