Healthcare Provider Details

I. General information

NPI: 1306178595
Provider Name (Legal Business Name): PATRICE MARIE STAMOS LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/12/2010
Last Update Date: 03/14/2023
Certification Date: 03/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

66 CLUB RD STE 160
EUGENE OR
97401-2439
US

IV. Provider business mailing address

PO BOX 70779
SPRINGFIELD OR
97475-0137
US

V. Phone/Fax

Practice location:
  • Phone: 541-345-1722
  • Fax: 541-485-7049
Mailing address:
  • Phone: 541-345-1722
  • Fax: 541-485-7049

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149.015677
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number103382
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberL12651
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier12166327
Identifier TypeOTHER
Identifier State
Identifier IssuerCAQH ID
# 2
Identifier500799653
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: