Provider Demographics
NPI:1588374219
Name:DEFRIES, STACEY ANN
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:ANN
Last Name:DEFRIES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:STACEY
Other - Middle Name:
Other - Last Name:DEFRIES
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LICSW
Mailing Address - Street 1:8042 14TH AVE NW
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98117-4230
Mailing Address - Country:US
Mailing Address - Phone:206-372-7555
Mailing Address - Fax:
Practice Address - Street 1:8042 14TH AVE NW
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98117-4230
Practice Address - Country:US
Practice Address - Phone:206-372-7555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-05
Last Update Date:2022-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALW606418921041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical