Provider Demographics
NPI:1508156456
Name:STOLLER, MARY SUE (DC)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:SUE
Last Name:STOLLER
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6200 SW VIRGINIA AVE
Mailing Address - Street 2:SUITE 204
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-3638
Mailing Address - Country:US
Mailing Address - Phone:503-892-3802
Mailing Address - Fax:503-892-3802
Practice Address - Street 1:6200 SW VIRGINIA AVE
Practice Address - Street 2:SUITE 204
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-3638
Practice Address - Country:US
Practice Address - Phone:503-892-3802
Practice Address - Fax:503-892-3802
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-12
Last Update Date:2011-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3271111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor