Basic Information
| Provider Information | |||||||||
| NPI: | 1699062711 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ELLIS | ||||||||
| FirstName: | STACY | ||||||||
| MiddleName: | LYNN | ||||||||
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| Credential: | PSYD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2204 SE 12TH AVE APT C | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972145338 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3109915923 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2621 NE 134TH ST STE 340 | ||||||||
| Address2: | |||||||||
| City: | VANCOUVER | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986863036 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604500140 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2011 | ||||||||
| LastUpdateDate: | 08/17/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | PY60509345 | WA | Y | Behavioral Health & Social Service Providers | Psychologist |
No ID Information.