Provider Demographics
NPI:1851838767
Name:CANALES BASURTO, STEPHANIE MARIA
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:MARIA
Last Name:CANALES BASURTO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12636 SE STARK ST STE 125
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97233-1058
Mailing Address - Country:US
Mailing Address - Phone:503-253-4600
Mailing Address - Fax:503-253-4609
Practice Address - Street 1:12636 SE STARK ST STE 125
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97233-1058
Practice Address - Country:US
Practice Address - Phone:503-253-4600
Practice Address - Fax:503-253-4609
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-30
Last Update Date:2024-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORT2451106H00000X
OR22-12-10524101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)