Provider Demographics
NPI:1861843310
Name:STACY J NIELSEN, LCSW, LLC
Entity Type:Organization
Organization Name:STACY J NIELSEN, LCSW, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STACY
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:NIELSEN
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:541-802-6597
Mailing Address - Street 1:11 SW BRANTLEY DR
Mailing Address - Street 2:
Mailing Address - City:WINSTON
Mailing Address - State:OR
Mailing Address - Zip Code:97496
Mailing Address - Country:US
Mailing Address - Phone:541-679-0366
Mailing Address - Fax:
Practice Address - Street 1:11 SW BRANTLEY DR
Practice Address - Street 2:
Practice Address - City:WINSTON
Practice Address - State:OR
Practice Address - Zip Code:97496-4526
Practice Address - Country:US
Practice Address - Phone:541-679-0366
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-27
Last Update Date:2016-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL6376251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health