Provider Demographics
NPI:1770198533
Name:HEINLE, STACY JANE
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:JANE
Last Name:HEINLE
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 1:16612 124TH AVE SE
Mailing Address - Street 2:
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98058-5364
Mailing Address - Country:US
Mailing Address - Phone:425-830-7809
Mailing Address - Fax:
Practice Address - Street 1:16612 124TH AVE SE
Practice Address - Street 2:
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98058-5364
Practice Address - Country:US
Practice Address - Phone:425-830-7809
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-09
Last Update Date:2020-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALW000094881041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical