Basic Information
| Provider Information | |||||||||
| NPI: | 1407034929 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WHITE | ||||||||
| FirstName: | STACEY | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | CADC-II, B.S. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2586 12TH PL SE | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973022536 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5033714160 | ||||||||
| FaxNumber: | 5033759727 | ||||||||
| Practice Location | |||||||||
| Address1: | 2586 12TH PL SE | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973022536 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5033714160 | ||||||||
| FaxNumber: | 5033759727 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/06/2008 | ||||||||
| LastUpdateDate: | 02/06/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | OR | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.