Provider Demographics
NPI:1801217955
Name:BALLIET, STEPHANIE SEBILLE (RN)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:SEBILLE
Last Name:BALLIET
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:COLLEEN
Other - Last Name:SEBILLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
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:
Mailing Address - Fax:
Practice Address - Street 1:2415 SE 43RD AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97206-1600
Practice Address - Country:US
Practice Address - Phone:503-238-0705
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-16
Last Update Date:2013-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
OR201392304RN163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health