Provider Demographics
NPI:1548312887
Name:STUCKEY, MARC FREDERICK (PSYD)
Entity type:Individual
Prefix:DR
First Name:MARC
Middle Name:FREDERICK
Last Name:STUCKEY
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:328 W MAIN STREET
Mailing Address - Street 2:SUITE A100
Mailing Address - City:HILLSBORO
Mailing Address - State:OR
Mailing Address - Zip Code:97123
Mailing Address - Country:US
Mailing Address - Phone:503-313-0395
Mailing Address - Fax:503-681-4794
Practice Address - Street 1:328 W MAIN STREET
Practice Address - Street 2:SUITE A100
Practice Address - City:HILLSBORO
Practice Address - State:OR
Practice Address - Zip Code:97123
Practice Address - Country:US
Practice Address - Phone:503-313-0395
Practice Address - Fax:503-681-4794
Is Sole Proprietor?:No
Enumeration Date:2007-01-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1549103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR231990Medicaid