Provider Demographics
NPI:1427485440
Name:STACER, SHANEEN DIANE (PHD)
Entity type:Individual
Prefix:DR
First Name:SHANEEN
Middle Name:DIANE
Last Name:STACER
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:SHANEEN
Other - Middle Name:DIANE
Other - Last Name:MESKEW
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHD
Mailing Address - Street 1:1900 WOODLAND DR
Mailing Address - Street 2:
Mailing Address - City:COOS BAY
Mailing Address - State:OR
Mailing Address - Zip Code:97420-2045
Mailing Address - Country:US
Mailing Address - Phone:541-267-5151
Mailing Address - Fax:541-266-4554
Practice Address - Street 1:1900 WOODLAND DR
Practice Address - Street 2:
Practice Address - City:COOS BAY
Practice Address - State:OR
Practice Address - Zip Code:97420-2045
Practice Address - Country:US
Practice Address - Phone:541-267-5151
Practice Address - Fax:541-266-4554
Is Sole Proprietor?:No
Enumeration Date:2013-10-04
Last Update Date:2016-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3079-57103T00000X, 103TA0400X, 103TB0200X, 103TC0700X, 103TC2200X, 103TH0004X, 103TH0100X, 103TP2701X
OR2500103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TH0004XBehavioral Health & Social Service ProvidersPsychologistHealth
No103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service
No103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup Psychotherapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR161133OtherNORTH BEND MEDICAL CENTER GROUP MEDICAID
ORR0000WFBTVOtherNORTH BEND MEDICAL CENTER GROUP MEDICARE
OR500684206Medicaid
OR1407812365OtherNORTH BEND MEDICAL CENTER GROUP NPI
ORR0000WFBTVOtherNORTH BEND MEDICAL CENTER GROUP MEDICARE