Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 101YA0400X | Addiction Counselor (Substance Use Disorder) |
NPI | 1003260571 |
---|---|
Provider Name | Desiree Dawn Stang |
First Address | Portland, OR 97232-3139 |
Second Address | Portland, OR 97232-3139 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 20/04/2016 |
Last Update Date | 27/01/2019 |