Provider Demographics
NPI:1255834271
Name:SAMPSON, PATRICIA STACK
Entity type:Individual
Prefix:
First Name:PATRICIA
Middle Name:STACK
Last Name:SAMPSON
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 1:1732 N 6TH AVE
Mailing Address - Street 2:
Mailing Address - City:STAYTON
Mailing Address - State:OR
Mailing Address - Zip Code:97383-1236
Mailing Address - Country:US
Mailing Address - Phone:503-580-9068
Mailing Address - Fax:
Practice Address - Street 1:2340 MARTIN DR STE 103
Practice Address - Street 2:
Practice Address - City:STAYTON
Practice Address - State:OR
Practice Address - Zip Code:97383-1672
Practice Address - Country:US
Practice Address - Phone:503-509-5275
Practice Address - Fax:503-509-2933
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-15
Last Update Date:2018-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health