Provider Demographics
NPI:1093010845
Name:WHITMORE, STACEY R (BS)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:R
Last Name:WHITMORE
Suffix:
Gender:M
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 E OLIVE ST
Mailing Address - Street 2:SOUND MENTAL HEALTH
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98122-2735
Mailing Address - Country:US
Mailing Address - Phone:206-302-2200
Mailing Address - Fax:206-302-2210
Practice Address - Street 1:11629 AVONDALE RD NE
Practice Address - Street 2:AVONDALE HOUSE
Practice Address - City:REDMOND
Practice Address - State:WA
Practice Address - Zip Code:98052-2201
Practice Address - Country:US
Practice Address - Phone:425-653-5080
Practice Address - Fax:425-653-5081
Is Sole Proprietor?:No
Enumeration Date:2011-01-25
Last Update Date:2011-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACG60199775101Y00000X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor