Provider Demographics
NPI:1508234550
Name:STUBBLEFIELD, ADELLE S (LICSW)
Entity Type:Individual
Prefix:
First Name:ADELLE
Middle Name:S
Last Name:STUBBLEFIELD
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 ROGER LN
Mailing Address - Street 2:
Mailing Address - City:ELMA
Mailing Address - State:WA
Mailing Address - Zip Code:98541-9504
Mailing Address - Country:US
Mailing Address - Phone:208-908-6399
Mailing Address - Fax:
Practice Address - Street 1:418 E 1ST ST STE 209
Practice Address - Street 2:
Practice Address - City:ABERDEEN
Practice Address - State:WA
Practice Address - Zip Code:98520-4116
Practice Address - Country:US
Practice Address - Phone:360-747-7414
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-08
Last Update Date:2022-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLMSW-34901104100000X
WALW60983270101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1508234550Medicaid