Provider Demographics
NPI:1225494867
Name:STACY, KATE BEVERLY
Entity Type:Individual
Prefix:MRS
First Name:KATE
Middle Name:BEVERLY
Last Name:STACY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KATHLEEN
Other - Middle Name:
Other - Last Name:STACY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1845
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98668-1845
Mailing Address - Country:US
Mailing Address - Phone:360-384-8484
Mailing Address - Fax:360-397-8494
Practice Address - Street 1:1601 E 4TH PLAIN BLVD
Practice Address - Street 2:BLDG 17 STE B222
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98661-3713
Practice Address - Country:US
Practice Address - Phone:360-397-8484
Practice Address - Fax:360-397-8494
Is Sole Proprietor?:No
Enumeration Date:2016-01-12
Last Update Date:2016-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACO60619612101YA0400X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)