Provider Demographics
NPI:1154812923
Name:WILLIAMS, STACY J (CADC I, CRM)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:J
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:CADC I, CRM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3020 BRENNA AVE NE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-8056
Mailing Address - Country:US
Mailing Address - Phone:971-218-2763
Mailing Address - Fax:
Practice Address - Street 1:525 FERRY ST SE STE 203
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-3743
Practice Address - Country:US
Practice Address - Phone:503-363-0833
Practice Address - Fax:503-363-0833
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-28
Last Update Date:2018-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR18-P-02101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)