Provider Demographics
NPI:1992725451
Name:MONG, SHANNON (PSYD)
Entity type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:
Last Name:MONG
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:922 NW CIRCLE BLVD UNIT 160-222
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97330-1483
Mailing Address - Country:US
Mailing Address - Phone:415-914-4276
Mailing Address - Fax:
Practice Address - Street 1:922 NW CIRCLE BLVD # 160-222
Practice Address - Street 2:
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97330-1483
Practice Address - Country:US
Practice Address - Phone:415-914-4276
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-20
Last Update Date:2025-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20722103TC2200X, 103TC0700X
OR3803103TC0700X, 103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPSY20722OtherPSYCHOLOGIST LICENSE
ORPSY3803OtherPSYCHOLOGIST LICENSE