Provider Demographics
NPI:1033985379
Name:ENSERINK, STACI NICOLE
Entity Type:Individual
Prefix:
First Name:STACI
Middle Name:NICOLE
Last Name:ENSERINK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:616 W LUELLEN DR # 11
Mailing Address - Street 2:
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97471-2618
Mailing Address - Country:US
Mailing Address - Phone:541-643-9763
Mailing Address - Fax:
Practice Address - Street 1:545 W UMPQUA ST STE 1
Practice Address - Street 2:
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97471-2979
Practice Address - Country:US
Practice Address - Phone:541-957-5646
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-28
Last Update Date:2023-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health