Provider Demographics
NPI:1386277150
Name:WILSON, STACY ANN (CRM, QMHA, CADC)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:ANN
Last Name:WILSON
Suffix:
Gender:
Credentials:CRM, QMHA, CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2901 E BURNSIDE ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214-1831
Mailing Address - Country:US
Mailing Address - Phone:503-238-5203
Mailing Address - Fax:
Practice Address - Street 1:2901 E BURNSIDE ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97214-1831
Practice Address - Country:US
Practice Address - Phone:503-238-5203
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-19
Last Update Date:2025-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR24-QMHA-I-004213174400000X
OR20-CRM-007175T00000X
OR25-03-11415101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No174400000XOther Service ProvidersSpecialist
No175T00000XOther Service ProvidersPeer Specialist