Provider Demographics
NPI:1578738167
Name:NILSON, STACIA LYNNAE (LPC)
Entity Type:Individual
Prefix:MS
First Name:STACIA
Middle Name:LYNNAE
Last Name:NILSON
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6107 SW MURRAY BLVD
Mailing Address - Street 2:#296
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97008-4421
Mailing Address - Country:US
Mailing Address - Phone:503-619-9587
Mailing Address - Fax:
Practice Address - Street 1:2525 NW LOVEJOY ST
Practice Address - Street 2:SUITE 211
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97210-2859
Practice Address - Country:US
Practice Address - Phone:503-619-9587
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-24
Last Update Date:2013-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health