Provider Demographics
NPI:1023688439
Name:SHADE TREE COUNSELING
Entity type:Organization
Organization Name:SHADE TREE COUNSELING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:NIELSEN
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:503-949-1026
Mailing Address - Street 1:4210 BARRETT ST S
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97302-6106
Mailing Address - Country:US
Mailing Address - Phone:503-949-1026
Mailing Address - Fax:
Practice Address - Street 1:4210 BARRETT ST S
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302-6106
Practice Address - Country:US
Practice Address - Phone:503-949-1026
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-28
Last Update Date:2021-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR1861556425Medicaid
OR1508083601Medicaid
OR1902279334Medicaid