Provider Demographics
NPI:1326555293
Name:EVANGER, STACY JEAN (CDP)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:JEAN
Last Name:EVANGER
Suffix:
Gender:F
Credentials:CDP
Other - Prefix:
Other - First Name:STACY
Other - Middle Name:JEAN
Other - Last Name:EVANGER-JENKINS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:821 SW 135TH ST
Mailing Address - Street 2:
Mailing Address - City:BURIEN
Mailing Address - State:WA
Mailing Address - Zip Code:98146-3147
Mailing Address - Country:US
Mailing Address - Phone:206-391-3563
Mailing Address - Fax:
Practice Address - Street 1:901 RAINIER AVE S
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98144-2839
Practice Address - Country:US
Practice Address - Phone:206-889-0569
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-02
Last Update Date:2018-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WACP60390363OtherCDP