Basic Information
| Provider Information | |||||||||
| NPI: | 1427485440 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STACER | ||||||||
| FirstName: | SHANEEN | ||||||||
| MiddleName: | DIANE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PHD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MESKEW | ||||||||
| OtherFirstName: | SHANEEN | ||||||||
| OtherMiddleName: | DIANE | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PHD | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1900 WOODLAND DR | ||||||||
| Address2: | |||||||||
| City: | COOS BAY | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974202045 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412675151 | ||||||||
| FaxNumber: | 5412664554 | ||||||||
| Practice Location | |||||||||
| Address1: | 1900 WOODLAND DR | ||||||||
| Address2: | |||||||||
| City: | COOS BAY | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974202045 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412675151 | ||||||||
| FaxNumber: | 5412664554 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2013 | ||||||||
| LastUpdateDate: | 09/08/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 3079-57 | WI | N | Behavioral Health & Social Service Providers | Psychologist | 103TA0400X | 3079-57 | WI | N | Behavioral Health & Social Service Providers | Psychologist | Addiction (Substance Use Disorder) | 103TB0200X | 3079-57 | WI | N | Behavioral Health & Social Service Providers | Psychologist | Cognitive & Behavioral | 103TC0700X | 3079-57 | WI | N | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103TC2200X | 3079-57 | WI | N | Behavioral Health & Social Service Providers | Psychologist | Clinical Child & Adolescent | 103TH0004X | 3079-57 | WI | N | Behavioral Health & Social Service Providers | Psychologist | Health | 103TH0100X | 3079-57 | WI | N | Behavioral Health & Social Service Providers | Psychologist | Health Service | 103TP2701X | 3079-57 | WI | N | Behavioral Health & Social Service Providers | Psychologist | Group Psychotherapy | 103TC0700X | 2500 | OR | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 161133 | 01 | OR | NORTH BEND MEDICAL CENTER GROUP MEDICAID | OTHER | R0000WFBTV | 01 | OR | NORTH BEND MEDICAL CENTER GROUP MEDICARE | OTHER | 500684206 | 05 | OR | MEDICAID | 1407812365 | 01 | OR | NORTH BEND MEDICAL CENTER GROUP NPI | OTHER |