Provider Demographics
NPI:1902173941
Name:BUNNELL, STACY (MA)
Entity Type:Individual
Prefix:MS
First Name:STACY
Middle Name:
Last Name:BUNNELL
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16535 SW TUALATIN VALLEY HWY
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97003-5143
Mailing Address - Country:US
Mailing Address - Phone:503-259-3131
Mailing Address - Fax:503-649-7405
Practice Address - Street 1:16535 SW TUALATIN VALLEY HWY
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97003-5143
Practice Address - Country:US
Practice Address - Phone:503-259-3131
Practice Address - Fax:503-649-7405
Is Sole Proprietor?:No
Enumeration Date:2011-11-18
Last Update Date:2015-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
WALH60534215101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor