Shannon Dwayne Kretz, AA, CDPT

Primary specialty

CounselorTaxonomy code 101Y00000X

License

60871961 Issued in WA

Practice address

309 Oak St
Kelso, WA 98626-2340

Phone

(360) 423-0203

Fax

(360) 577-7904

NPI assigned

Sep 25, 2018

Last updated

Feb 5, 2019By the provider in NPPES

Sex

Male

Sole proprietor

No

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

Specialties & licenses 1

Addresses

Other identifiers 1

Other names 1

• Shannon Dwayne Benjamin Other name

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

Credentials

Associate of Arts

State licenses

Practice roles

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

• C & R Executives, LLC

  dba A First Place

  • Addiction (Substance Use Disorder) Counselor
  • Kelso, WA
  • NPI 1134373574
  NPD (past)

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

{
    "created_epoch": "1537833600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1549324800000",
    "number": "1861977936",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "921 14TH AVENUE",
            "city": "LONGVIEW",
            "state": "WA",
            "postal_code": "98632",
            "telephone_number": "360-423-0203",
            "fax_number": "360-577-0269"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "309 OAK ST",
            "city": "KELSO",
            "state": "WA",
            "postal_code": "986262340",
            "telephone_number": "360-423-0203",
            "fax_number": "360-577-7904"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "KRETZ",
        "first_name": "SHANNON",
        "middle_name": "DWAYNE",
        "credential": "AA, CDPT",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2018-09-25",
        "last_updated": "2019-02-05",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "101Y00000X",
            "taxonomy_group": "",
            "desc": "Counselor",
            "state": "WA",
            "license": "60871961",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "2108137",
            "state": "WA"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "first_name": "SHANNON",
            "last_name": "BENJAMIN",
            "middle_name": "DWAYNE",
            "code": "5",
            "type": "Other Name"
        }
    ]
}

• Elena V Khorosheva-Brown, LPN, GEM-STONE THERA
• Danny Barton Kilgore, LPN
• Brandy Kmetz
• Elena Koleva
• Zachariah Kramer, M.D.
• Amy E Kyle
• Cindy Abbott Kyle, CCC-SLP
• Kimber Lacey, NEUROLINGUISTIC PRAC
• Kevin David Lampshire
• Robin Lander

• Counselor in Kelso, WA
• Providers in Kelso, WA by specialty
• Counselor in Washington

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 5, 2019; 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.