Provider Demographics
NPI:1780399808
Name:BURDICK, STACY (DM- BCC (2054))
Entity type:Individual
Prefix:DR
First Name:STACY
Middle Name:
Last Name:BURDICK
Suffix:
Gender:M
Credentials:DM- BCC (2054)
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1230 WESTWOOD DR NW
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97304-3749
Mailing Address - Country:US
Mailing Address - Phone:971-208-4663
Mailing Address - Fax:
Practice Address - Street 1:1230 WESTWOOD DR NW
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97304-3749
Practice Address - Country:US
Practice Address - Phone:971-208-4663
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-23
Last Update Date:2023-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL2054374K00000X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No374K00000XNursing Service Related ProvidersReligious Nonmedical Practitioner