Provider Demographics
NPI:1407427719
Name:STACKPOOLE, MARISA ANN
Entity Type:Individual
Prefix:
First Name:MARISA
Middle Name:ANN
Last Name:STACKPOOLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 W MAIN ST STE 4B
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97501-2734
Mailing Address - Country:US
Mailing Address - Phone:541-414-1720
Mailing Address - Fax:
Practice Address - Street 1:2368 CRATER LAKE AVE STE 102
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-5006
Practice Address - Country:US
Practice Address - Phone:541-727-1592
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-07
Last Update Date:2022-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health