Provider Demographics
NPI:1093521684
Name:CALLIOUX, STACY CARMEN
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:CARMEN
Last Name:CALLIOUX
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24047 192ND PL SE
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:WA
Mailing Address - Zip Code:98042-4844
Mailing Address - Country:US
Mailing Address - Phone:206-755-1026
Mailing Address - Fax:
Practice Address - Street 1:11803 101ST AVE E
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98373-3473
Practice Address - Country:US
Practice Address - Phone:253-881-1428
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-09
Last Update Date:2024-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist