Active NPI
Gladys Shade, QMHP, LCSW
- Clinical Social Worker
- North Bend, OR
National Provider Identifier
1114137494
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Clinical Social Worker
- License
- 3124
- Practice address
- 1890 Waite St
Suite 1
North Bend, OR 97459-1229 - Phone
- (541) 756-6232
- Fax
- (541) 756-6234
- NPI assigned
- May 23, 2007
- Sex
- Female
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Clinical Social Worker | 1041C0700X | 3124 | OR | Primary |
Addresses
Primary practice location
1890 Waite St
Suite 1
North Bend, OR 97459-1229
Mailing address
1890 Waite St
Suite 1
North Bend, OR 97459-1229
Phone (541) 756-6232
Other identifiers 4
| Identifier | Type | State | Issuer |
|---|---|---|---|
| R142063 | Other | OR | MEDICARE PTAN |
| 1619915113 | Other | OR | GROUP NUMBER NPI |
| R120353 | Other | PTAN | |
| 213342 | Medicaid | OR |
Other names 1
- Ms. Alex Shade
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 3124 | OR | MD | Clinical Social Worker |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1179878400000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1228176000000",
"number": "1114137494",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "1890 WAITE ST",
"address_2": "SUITE 1",
"city": "NORTH BEND",
"state": "OR",
"postal_code": "974591229",
"telephone_number": "541-756-6232",
"fax_number": "541-756-6234"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "1890 WAITE ST",
"address_2": "SUITE 1",
"city": "NORTH BEND",
"state": "OR",
"postal_code": "974591229",
"telephone_number": "541-756-6232",
"fax_number": "541-756-6234"
}
],
"practiceLocations": [],
"basic": {
"last_name": "SHADE",
"first_name": "GLADYS",
"name_prefix": "Ms.",
"credential": "QMHP, LCSW",
"sole_proprietor": "NO",
"sex": "F",
"enumeration_date": "2007-05-23",
"last_updated": "2008-12-02",
"status": "A"
},
"taxonomies": [
{
"code": "1041C0700X",
"taxonomy_group": "",
"desc": "Social Worker, Clinical",
"state": "OR",
"license": "3124",
"primary": true
}
],
"identifiers": [
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "MEDICARE PTAN",
"identifier": "R142063",
"state": "OR"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "GROUP NUMBER NPI",
"identifier": "1619915113",
"state": "OR"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "PTAN",
"identifier": "R120353",
"state": null
},
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "213342",
"state": "OR"
}
],
"endpoints": [],
"other_names": [
{
"first_name": "ALEX",
"last_name": "SHADE",
"prefix": "MS.",
"code": "2",
"type": "Professional Name"
}
]
}Other providers in North Bend, OR
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 2, 2008; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.