Provider Demographics
NPI:1073981791
Name:STANISLOO, TAMMY
Entity Type:Individual
Prefix:
First Name:TAMMY
Middle Name:
Last Name:STANISLOO
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 1:715 SW RAMSEY AVE
Mailing Address - Street 2:
Mailing Address - City:GRANTS PASS
Mailing Address - State:OR
Mailing Address - Zip Code:97527-5500
Mailing Address - Country:US
Mailing Address - Phone:541-956-5463
Mailing Address - Fax:
Practice Address - Street 1:1913 MEADE ST
Practice Address - Street 2:
Practice Address - City:NORTH BEND
Practice Address - State:OR
Practice Address - Zip Code:97459-3432
Practice Address - Country:US
Practice Address - Phone:541-756-4508
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-11
Last Update Date:2015-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health