Provider Demographics
NPI:1932630522
Name:HARRISON, STACIE NICHOLE (LMSW, LCSW)
Entity type:Individual
Prefix:MRS
First Name:STACIE
Middle Name:NICHOLE
Last Name:HARRISON
Suffix:
Gender:F
Credentials:LMSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6885 OTTER CREST LOOP
Mailing Address - Street 2:
Mailing Address - City:OTTER ROCK
Mailing Address - State:OR
Mailing Address - Zip Code:97369-9711
Mailing Address - Country:US
Mailing Address - Phone:208-206-9480
Mailing Address - Fax:
Practice Address - Street 1:51 SW LEE ST
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:OR
Practice Address - Zip Code:97365-3823
Practice Address - Country:US
Practice Address - Phone:541-574-5960
Practice Address - Fax:541-265-0601
Is Sole Proprietor?:No
Enumeration Date:2017-03-24
Last Update Date:2017-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID35928101YM0800X
ORNON-LICENSED CSWA101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500722862Medicaid