Provider Demographics
NPI:1629291307
Name:STUART, CAROL JO (PSYD)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:JO
Last Name:STUART
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2607
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-2607
Mailing Address - Country:US
Mailing Address - Phone:503-827-4800
Mailing Address - Fax:
Practice Address - Street 1:2188 SW PARK PL
Practice Address - Street 2:205
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97205-1100
Practice Address - Country:US
Practice Address - Phone:503-827-4800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1072103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist