Basic Information
Provider Information
NPI: 1467988345
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: STACEY
FirstName: SCOTT
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential: CRM
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 461 NE GREENWOOD AVE
Address2:  
City: BEND
State: OR
PostalCode: 977014607
CountryCode: US
TelephoneNumber: 5416177365
FaxNumber: 5415041195
Practice Location
Address1: 340 NW 5TH ST
Address2: BOX 1710
City: REDMOND
State: OR
PostalCode: 977561869
CountryCode: US
TelephoneNumber: 5415164087
FaxNumber: 5415041195
Other Information
ProviderEnumerationDate: 05/11/2017
LastUpdateDate: 05/11/2017
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
101YA0400X17-CRM-081ORY Behavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)

No ID Information.


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