Healthcare Provider Details

I. General information

NPI: 1659801173
Provider Name (Legal Business Name): STACEY PARK PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2017
Last Update Date: 06/25/2022
Certification Date: 06/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6314 19TH ST W STE 14
FIRCREST WA
98466-6223
US

IV. Provider business mailing address

6314 19TH ST W STE 14
FIRCREST WA
98466-6223
US

V. Phone/Fax

Practice location:
  • Phone: 253-239-2310
  • Fax: 253-239-2311
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License NumberPY60880262
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number28774
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: