MEDICARE: STACIE NICOLE FISH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor
2	101Y00000X	Counselor	C9713	OR

General Provider Information

NPI Number	:	1417536020
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STACIE NICOLE FISH

Provider Business Mailing Address
First Line	:	PO BOX 3417
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97208-3417
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	147 COMMERCIAL ST NE
Second Line	:
City	:	SALEM
State	:	OR
Zip	:	97301-3416
Country	:	US
Telephone Number	:	503-589-3122
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/02/2021
Last Update Date	:	05/06/2025

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Directions to “ STACIE NICOLE FISH ” Practice Location

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