MEDICARE: STEPHANIE MARIA POE MA, QMHP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	6860-MA	OTHER	OR	PACIFIC CARE
2	J4525-01	OTHER	OR	PACIFIC SOURCE
3	174029174029	OTHER	OR	LIFEWISE
4	A023	OTHER	OR	TRICARE

General Provider Information

NPI Number	:	1205020526
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STEPHANIE MARIA POE MA, QMHP

Provider Business Mailing Address
First Line	:	3107 GRAND AVE
Second Line	:
City	:	ASTORIA
State	:	OR
Zip	:	97103-2729
Country	:	US
Telephone Number	:	503-325-6754
Fax Number	:	503-338-6268

Provider Business Practice Location Address
First Line	:	3107 GRAND AVE
Second Line	:
City	:	ASTORIA
State	:	OR
Zip	:	97103-2729
Country	:	US
Telephone Number	:	503-325-6754
Fax Number	:	503-338-6268

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/29/2007
Last Update Date	:	08/29/2007

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