Provider Demographics
NPI:1801021159
Name:WENTLING, STACIE M (CSWA, QMHP, CADCI)
Entity Type:Individual
Prefix:
First Name:STACIE
Middle Name:M
Last Name:WENTLING
Suffix:
Gender:F
Credentials:CSWA, QMHP, CADCI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 8459
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97207-8459
Mailing Address - Country:US
Mailing Address - Phone:503-238-0769
Mailing Address - Fax:
Practice Address - Street 1:847 NE 19TH AVE STE 100
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97232-2684
Practice Address - Country:US
Practice Address - Phone:541-883-3471
Practice Address - Fax:541-883-3524
Is Sole Proprietor?:No
Enumeration Date:2009-05-15
Last Update Date:2019-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
ORA5434101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR1114058898Medicaid
OR18-01-16OtherCERTIFIED DRUG AND ALCOHOL COUNSELOR I
ORA5434OtherCLINICAL SOCIAL WORK ASSOCIATE