Provider Demographics
NPI:1861977936
Name:KRETZ, SHANNON DWAYNE (AA, CDPT)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:DWAYNE
Last Name:KRETZ
Suffix:
Gender:M
Credentials:AA, CDPT
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:DWAYNE
Other - Last Name:BENJAMIN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:921 14TH AVENUE
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632
Mailing Address - Country:US
Mailing Address - Phone:360-423-0203
Mailing Address - Fax:360-577-0269
Practice Address - Street 1:309 OAK ST
Practice Address - Street 2:
Practice Address - City:KELSO
Practice Address - State:WA
Practice Address - Zip Code:98626-2340
Practice Address - Country:US
Practice Address - Phone:360-423-0203
Practice Address - Fax:360-577-7904
Is Sole Proprietor?:No
Enumeration Date:2018-09-25
Last Update Date:2019-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60871961101Y00000X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2108137Medicaid