Provider Demographics
NPI:1316590144
Name:KELLER, STACEY MARLENE (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:STACEY
Middle Name:MARLENE
Last Name:KELLER
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 1:4204 SE 63RD AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97206-3767
Mailing Address - Country:US
Mailing Address - Phone:503-819-8903
Mailing Address - Fax:
Practice Address - Street 1:4400 NE HALSEY ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213-1545
Practice Address - Country:US
Practice Address - Phone:971-263-3942
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-21
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL77521041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical