Provider Demographics
NPI:1326159773
Name:MARY ANNE STOWELL LCSW, PC
Entity Type:Organization
Organization Name:MARY ANNE STOWELL LCSW, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MARY ANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:STOWELL
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:503-408-1759
Mailing Address - Street 1:4511 SE HAWTHORNE BLVD
Mailing Address - Street 2:SUITE 114
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97215-3170
Mailing Address - Country:US
Mailing Address - Phone:503-232-6868
Mailing Address - Fax:503-253-1285
Practice Address - Street 1:4511 SE HAWTHORNE BLVD
Practice Address - Street 2:SUITE 114
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97215-3170
Practice Address - Country:US
Practice Address - Phone:503-232-6868
Practice Address - Fax:503-253-1285
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2010-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL29341041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
0001095800OtherMHN
7299505OtherAETNA
OR825404000OtherREGENCE BLUE CROSS
OR182996Medicaid
330833000001OtherPROVIDENCE HEALTH PLAN
475273OtherHTH WORLD WIDE
=========OtherODS
=========OtherODS
330833000001OtherPROVIDENCE HEALTH PLAN