Healthcare Provider Details

I. General information

NPI: 1902173941
Provider Name (Legal Business Name): STACY BUNNELL M.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/18/2011
Last Update Date: 08/04/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16535 SW TUALATIN VALLEY HWY
BEAVERTON OR
97003-5143
US

IV. Provider business mailing address

16535 SW TUALATIN VALLEY HWY
BEAVERTON OR
97003-5143
US

V. Phone/Fax

Practice location:
  • Phone: 503-259-3131
  • Fax: 503-649-7405
Mailing address:
  • Phone: 503-259-3131
  • Fax: 503-649-7405

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLH60534215
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: