Provider Demographics
NPI:1659890887
Name:MANDZIJ, STACY L (LCSW)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:L
Last Name:MANDZIJ
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:STACIA
Other - Middle Name:L
Other - Last Name:MANDZIJ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LCSW
Mailing Address - Street 1:1776 SW MADISON ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97205-1715
Mailing Address - Country:US
Mailing Address - Phone:971-386-2278
Mailing Address - Fax:503-224-4494
Practice Address - Street 1:1310 SW 17TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97201-2522
Practice Address - Country:US
Practice Address - Phone:503-231-2641
Practice Address - Fax:503-467-4077
Is Sole Proprietor?:No
Enumeration Date:2017-09-19
Last Update Date:2020-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL8570104100000X
ORA4735104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500734958Medicaid