Provider Demographics
NPI:1306178595
Name:STAMOS, PATRICE MARIE (LCSW)
Entity Type:Individual
Prefix:
First Name:PATRICE
Middle Name:MARIE
Last Name:STAMOS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 70779
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OR
Mailing Address - Zip Code:97475-0137
Mailing Address - Country:US
Mailing Address - Phone:541-345-1722
Mailing Address - Fax:541-485-7049
Practice Address - Street 1:66 CLUB RD STE 160
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-2439
Practice Address - Country:US
Practice Address - Phone:541-345-1722
Practice Address - Fax:541-485-7049
Is Sole Proprietor?:No
Enumeration Date:2010-02-12
Last Update Date:2023-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0156771041C0700X
CA1033821041C0700X
ORL126511041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
12166327OtherCAQH ID
OR500799653Medicaid