Provider Demographics
NPI:1215068523
Name:YOUNG, STACY L (LCSW)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:L
Last Name:YOUNG
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 66553
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97290-6553
Mailing Address - Country:US
Mailing Address - Phone:503-490-9288
Mailing Address - Fax:503-762-0536
Practice Address - Street 1:10373 NE HANCOCK ST STE 220
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97220-3873
Practice Address - Country:US
Practice Address - Phone:503-490-9288
Practice Address - Fax:503-762-0536
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL2708101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health