Provider Demographics
NPI:1174754493
Name:KENNINGTON, SHANE D (LCSW)
Entity type:Individual
Prefix:MR
First Name:SHANE
Middle Name:D
Last Name:KENNINGTON
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1750 SW SKYLINE BLVD STE 206
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97221-2545
Mailing Address - Country:US
Mailing Address - Phone:503-327-5584
Mailing Address - Fax:971-351-6851
Practice Address - Street 1:1750 SW SKYLINE BLVD STE 206
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97221-2545
Practice Address - Country:US
Practice Address - Phone:503-327-5584
Practice Address - Fax:971-351-6851
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-04
Last Update Date:2023-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL70781041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACY261AMedicare PIN