Basic Information
| Provider Information | |||||||||
| NPI: | 1942702014 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BERRY | ||||||||
| FirstName: | STACEY | ||||||||
| MiddleName: | WARREN | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 82819 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972820819 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032335405 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 880 82ND DR | ||||||||
| Address2: | |||||||||
| City: | GLADSTONE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970271803 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032728031 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/06/2018 | ||||||||
| LastUpdateDate: | 08/07/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/07/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | S.160241 | OH | N | Behavioral Health & Social Service Providers | Social Worker | 163W00000X | RN.458469 | OH | N | Nursing Service Providers | Registered Nurse | 363LP0808X | 202007113NP-PP | OR | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
No ID Information.