Provider Demographics
NPI:1679906507
Name:MCGRAW, STACIE PAGE
Entity Type:Individual
Prefix:
First Name:STACIE
Middle Name:PAGE
Last Name:MCGRAW
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:STACIE
Other - Middle Name:PAGE
Other - Last Name:WELLS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2491 CRESTBROOK DR NW
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97304-2752
Mailing Address - Country:US
Mailing Address - Phone:503-930-0272
Mailing Address - Fax:
Practice Address - Street 1:388 STATE ST STE 704
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-4023
Practice Address - Country:US
Practice Address - Phone:503-930-0272
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-14
Last Update Date:2024-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC5681101YP2500X
CA75987101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health