Healthcare Provider Details

I. General information

NPI: 1164979191
Provider Name (Legal Business Name): STONEYBROOKE RESIDENTIAL SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/07/2016
Last Update Date: 09/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25500 SE STARK ST SUITE 101
GRESHAM OR
97030-3331
US

IV. Provider business mailing address

25500 SE STARK ST SUITE 101
GRESHAM OR
97030-3331
US

V. Phone/Fax

Practice location:
  • Phone: 503-669-7191
  • Fax: 503-669-7102
Mailing address:
  • Phone: 503-669-7191
  • Fax: 503-669-7102

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: VALERIE STONEY
Title or Position: ASSISTANT DIRECTOR
Credential:
Phone: 503-669-7191