Provider Demographics
NPI:1407192461
Name:SHOOK, STACEY LYNN (PHD)
Entity Type:Individual
Prefix:MS
First Name:STACEY
Middle Name:LYNN
Last Name:SHOOK
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:711 N 35TH ST
Mailing Address - Street 2:APT. 102
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98103-3412
Mailing Address - Country:US
Mailing Address - Phone:206-390-0460
Mailing Address - Fax:425-828-3101
Practice Address - Street 1:3003 NORTHUP WAY
Practice Address - Street 2:SUITE 200
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98004-1471
Practice Address - Country:US
Practice Address - Phone:425-822-6442
Practice Address - Fax:425-828-3101
Is Sole Proprietor?:No
Enumeration Date:2012-12-19
Last Update Date:2012-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1-00-0065103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst