Provider Demographics
NPI:1205020526
Name:POE, STEPHANIE MARIA (MA, QMHP)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:MARIA
Last Name:POE
Suffix:
Gender:F
Credentials:MA, QMHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3107 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:OR
Mailing Address - Zip Code:97103-2729
Mailing Address - Country:US
Mailing Address - Phone:503-325-6754
Mailing Address - Fax:503-338-6268
Practice Address - Street 1:3107 GRAND AVE
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:OR
Practice Address - Zip Code:97103-2729
Practice Address - Country:US
Practice Address - Phone:503-325-6754
Practice Address - Fax:503-338-6268
Is Sole Proprietor?:No
Enumeration Date:2007-08-29
Last Update Date:2007-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR6860-MAOtherPACIFIC CARE
ORJ4525-01OtherPACIFIC SOURCE
OR174029174029OtherLIFEWISE
ORA023OtherTRICARE