Provider Demographics
NPI:1366894172
Name:SECRETT, SHARNISSA (LCSW)
Entity type:Individual
Prefix:MS
First Name:SHARNISSA
Middle Name:
Last Name:SECRETT
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10940 SE LONG ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97266-3449
Mailing Address - Country:US
Mailing Address - Phone:503-756-3997
Mailing Address - Fax:
Practice Address - Street 1:4110 NE 122ND AVE STE 115
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97230-1384
Practice Address - Country:US
Practice Address - Phone:503-756-3997
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-05
Last Update Date:2023-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL69411041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical