Provider Demographics
NPI:1417548470
Name:SEAL, STACEY (CADC 2)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:SEAL
Suffix:
Gender:F
Credentials:CADC 2
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:870 82ND DR BLDG C027
Mailing Address - Street 2:
Mailing Address - City:GLADSTONE
Mailing Address - State:OR
Mailing Address - Zip Code:97027-1803
Mailing Address - Country:US
Mailing Address - Phone:971-202-7193
Mailing Address - Fax:
Practice Address - Street 1:18600 SE MCLOUGHLIN BLVD
Practice Address - Street 2:
Practice Address - City:MILWAUKIE
Practice Address - State:OR
Practice Address - Zip Code:97267-6723
Practice Address - Country:US
Practice Address - Phone:503-735-5931
Practice Address - Fax:503-239-8407
Is Sole Proprietor?:No
Enumeration Date:2021-02-01
Last Update Date:2024-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1417548470101YA0400X
101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)