Provider Demographics
NPI:1972994663
Name:MAHONEY, STACEY RAE (MSW, CADC II)
Entity type:Individual
Prefix:MRS
First Name:STACEY
Middle Name:RAE
Last Name:MAHONEY
Suffix:
Gender:F
Credentials:MSW, CADC II
Other - Prefix:MS
Other - First Name:STACEY
Other - Middle Name:RAE
Other - Last Name:WOOD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3181 SW SAM JACKSON PARK RD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-3011
Mailing Address - Country:US
Mailing Address - Phone:503-494-2273
Mailing Address - Fax:503-494-7979
Practice Address - Street 1:3181 SW SAM JACKSON PARK RD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-3011
Practice Address - Country:US
Practice Address - Phone:503-494-2273
Practice Address - Fax:503-494-7979
Is Sole Proprietor?:No
Enumeration Date:2015-02-17
Last Update Date:2020-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1041C0700X
ORL66501041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical