Healthcare Provider Details

I. General information

NPI: 1306991559
Provider Name (Legal Business Name): STACIE LYNN OVERBAY LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/25/2007
Last Update Date: 04/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

MADIGAN ARMY MEDICAL CENTER 9040 JACKSON AVE
TACOMA WA
98431-1100
US

IV. Provider business mailing address

MADIGAN ARMY MEDICAL CENTER 9040 JACKSON AVE
TACOMA WA
98431
US

V. Phone/Fax

Practice location:
  • Phone: 253-968-2252
  • Fax: 253-968-3278
Mailing address:
  • Phone: 253-966-6508
  • Fax: 253-967-8192

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberRC00054154
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLW60408899
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: