Basic Information
| Provider Information | |||||||||
| NPI: | 1922085307 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | IVERSON | ||||||||
| FirstName: | SHAWNA | ||||||||
| MiddleName: | DEANNE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MOT OTR L | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WALLACE | ||||||||
| OtherFirstName: | SHAWNA | ||||||||
| OtherMiddleName: | DEANNE | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1402 GWINN ST E | ||||||||
| Address2: | |||||||||
| City: | MONMOUTH | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97361 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5035105814 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 290 MOYER LN NW | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97304 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5033708990 | ||||||||
| FaxNumber: | 5033634214 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/28/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 1053130 | OR | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
ID Information
| ID | Type | State | Issuer | Description | 276082 | 05 | OR | MEDICAID |