Provider Demographics
NPI:1760879910
Name:SPEELMAN, STACEY (LISW-S, LICSW)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:SPEELMAN
Suffix:
Gender:F
Credentials:LISW-S, LICSW
Other - Prefix:
Other - First Name:STACEY
Other - Middle Name:RENEE
Other - Last Name:GOODING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1616 CORNWALL AVE STE 205
Mailing Address - Street 2:
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98225-4642
Mailing Address - Country:US
Mailing Address - Phone:360-676-6177
Mailing Address - Fax:360-671-3574
Practice Address - Street 1:6060 PORTAL WAY
Practice Address - Street 2:
Practice Address - City:FERNDALE
Practice Address - State:WA
Practice Address - Zip Code:98248-7833
Practice Address - Country:US
Practice Address - Phone:360-676-6177
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-24
Last Update Date:2019-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI12006791041C0700X
WALW605546991041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical