Basic Information
| Provider Information | |||||||||
| NPI: | 1932630522 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HARRISON | ||||||||
| FirstName: | STACIE | ||||||||
| MiddleName: | NICHOLE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LMSW, LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6885 OTTER CREST LOOP | ||||||||
| Address2: | |||||||||
| City: | OTTER ROCK | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973699711 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082069480 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 51 SW LEE ST | ||||||||
| Address2: | |||||||||
| City: | NEWPORT | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973653823 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5415745960 | ||||||||
| FaxNumber: | 5412650601 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/24/2017 | ||||||||
| LastUpdateDate: | 04/07/2017 | ||||||||
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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 | 101YM0800X | 35928 | ID | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YM0800X | NON-LICENSED CSWA | OR | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 500722862 | 05 | OR | MEDICAID |