Healthcare Provider Details

I. General information

NPI: 1881607059
Provider Name (Legal Business Name): THOMAS GEORGE STUCK M.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/15/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2400 LANCASTER DR NE
SALEM OR
97305-1221
US

IV. Provider business mailing address

3595 CRESTVIEW DR S
SALEM OR
97302-5658
US

V. Phone/Fax

Practice location:
  • Phone: 503-361-5400
  • Fax:
Mailing address:
  • Phone: 503-399-1603
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberOR 96-10-165
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: