Provider Demographics
NPI:1629571559
Name:BILLMYRE, STEPHANIE MICHELLE
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:MICHELLE
Last Name:BILLMYRE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:MICHELLE
Other - Last Name:MESTERHEIDE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1614
Mailing Address - Street 2:
Mailing Address - City:CLACKAMAS
Mailing Address - State:OR
Mailing Address - Zip Code:97015-1614
Mailing Address - Country:US
Mailing Address - Phone:971-277-0601
Mailing Address - Fax:
Practice Address - Street 1:1010 NE 165TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97230-6102
Practice Address - Country:US
Practice Address - Phone:971-353-8052
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-16
Last Update Date:2022-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500804330Medicaid