Provider Demographics
NPI:1760710792
Name:WORTH, STEPHANIE DANIELLE (LAC)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:DANIELLE
Last Name:WORTH
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1948 FURLONG PL
Mailing Address - Street 2:
Mailing Address - City:WEST LINN
Mailing Address - State:OR
Mailing Address - Zip Code:97068-2539
Mailing Address - Country:US
Mailing Address - Phone:971-404-7185
Mailing Address - Fax:
Practice Address - Street 1:831 NW COUNCIL DR STE 301
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-3725
Practice Address - Country:US
Practice Address - Phone:503-661-9700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-02
Last Update Date:2009-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAC150256171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist