1356788681 NPI number — MISS STACY LYNN WIRTH M.A. L.P.C.

Table of content: MISS STACY LYNN WIRTH M.A. L.P.C. (NPI 1356788681)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356788681 NPI number — MISS STACY LYNN WIRTH M.A. L.P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WIRTH
Provider First Name:
STACY
Provider Middle Name:
LYNN
Provider Name Prefix Text:
MISS
Provider Name Suffix Text:
Provider Credential Text:
M.A. L.P.C.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1356788681
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/28/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4216 SE 73RD AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORTLAND
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97206-3406
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-929-3231
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
516 SE MORRISON ST
Provider Second Line Business Practice Location Address:
SUITE 305
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97214-2327
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-593-6835
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/28/2013

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X , with the licence number:  C2984 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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