Basic Information
| Provider Information | |||||||||
| NPI: | 1528597382 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PUGERUDE | ||||||||
| FirstName: | SHANNON | ||||||||
| MiddleName: | KATHLEEN | ||||||||
| NamePrefix: | |||||||||
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| Credential: | MS, QMHP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | STEVENSON | ||||||||
| OtherFirstName: | SHANNON | ||||||||
| OtherMiddleName: | KATHLEEN | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | MS | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3995 MARCOLA RD | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974777948 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417261465 | ||||||||
| FaxNumber: | 5417265085 | ||||||||
| Practice Location | |||||||||
| Address1: | 1195 NW WALL ST | ||||||||
| Address2: | |||||||||
| City: | BEND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 977031965 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417280062 | ||||||||
| FaxNumber: | 5413066733 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2017 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 175T00000X | Y |
No ID Information.