Provider Demographics
NPI:1467929406
Name:SCHMIDT, STACY
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:SCHMIDT
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 1:18360 CALDART AVE NE
Mailing Address - Street 2:
Mailing Address - City:POULSBO
Mailing Address - State:WA
Mailing Address - Zip Code:98370-8775
Mailing Address - Country:US
Mailing Address - Phone:360-396-3499
Mailing Address - Fax:
Practice Address - Street 1:26201 SIYAYA AVE NE
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:WA
Practice Address - Zip Code:98346-9367
Practice Address - Country:US
Practice Address - Phone:360-396-3499
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-29
Last Update Date:2018-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA530856D103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool