Shade Tree Counseling

Primary specialty

Mental Health Clinic/Center (Including Community Mental Health Center)Taxonomy code 261QM0801X

Legal business name

SHADE TREE COUNSELING

Practice address

4210 Barrett St S
Salem, OR 97302-6106

Phone

(503) 949-1026

NPI assigned

Jun 28, 2021

Last updated

Jun 28, 2021By the provider in NPPES

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Robert Wayne Nielsen, LCSW

Title

Partner

Phone

(503) 949-1026

Specialties & licenses 1

Addresses

Other identifiers 3

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1624838400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1624838400000",
    "number": "1023688439",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "4210 BARRETT ST S",
            "city": "SALEM",
            "state": "OR",
            "postal_code": "973026106",
            "telephone_number": "503-949-1026"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4210 BARRETT ST S",
            "city": "SALEM",
            "state": "OR",
            "postal_code": "973026106",
            "telephone_number": "503-949-1026"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SHADE TREE COUNSELING",
        "organizational_subpart": "NO",
        "enumeration_date": "2021-06-28",
        "last_updated": "2021-06-28",
        "certification_date": "2021-06-28",
        "status": "A",
        "authorized_official_last_name": "NIELSEN",
        "authorized_official_first_name": "ROBERT",
        "authorized_official_middle_name": "WAYNE",
        "authorized_official_title_or_position": "PARTNER",
        "authorized_official_telephone_number": "503-949-1026",
        "authorized_official_credential": "LCSW"
    },
    "taxonomies": [
        {
            "code": "261QM0801X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Mental Health (Including Community Mental Health Center)",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1902279334",
            "state": "OR"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1861556425",
            "state": "OR"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1508083601",
            "state": "OR"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Brady Michael Severns, BS
• Daniel Severns
• Dan G Sewell, MD
• Brian Sexton
• Brianna Nicole Sexton, MD
• Aidan James Shaffer
• Alex Renee Shaffer, PA-C
• Hannah Shaffer
• Kulsoom K Shah, L.AC.
• Michael Shahbazyan, RPH

• Mental Health Clinic/Center (Including Community Mental Health Center) in Salem, OR
• Providers in Salem, OR by specialty
• Mental Health Clinic/Center (Including Community Mental Health Center) in Oregon

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 28, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.