Provider Demographics
NPI:1760750400
Name:WIMBERLEY, STACEY V (BS, LMT)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:V
Last Name:WIMBERLEY
Suffix:
Gender:F
Credentials:BS, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3000 NE YELLOW RIBBON DR
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97701-7522
Mailing Address - Country:US
Mailing Address - Phone:541-948-4823
Mailing Address - Fax:
Practice Address - Street 1:365 NE KEARNEY AVE
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-4573
Practice Address - Country:US
Practice Address - Phone:541-948-4823
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-08
Last Update Date:2014-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR7644174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist