Individual
MS. GLADYS SHADE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
QMHP, LCSW
Contact information
Practice address
1890 WAITE ST, SUITE 1, NORTH BEND, OR 97459-1229
(541) 756-6232
(541) 756-6234
Mailing address
1890 WAITE ST, SUITE 1, NORTH BEND, OR 97459-1229
(541) 756-6232
(541) 756-6234
Taxonomy
Speciality
Code
Description
License number
State
1041C0700X
Clinical Social Worker
Primary
3124
OR
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1619915113
GROUP NUMBER NPI
OR
05
—
213342
—
OR
01
—
R120353
PTAN
—
01
—
R142063
MEDICARE PTAN
OR
Enumeration date
05/23/2007
Last updated
12/02/2008
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