Provider Demographics
NPI:1043039514
Name:BREWER-GORDON, STACEE
Entity type:Individual
Prefix:
First Name:STACEE
Middle Name:
Last Name:BREWER-GORDON
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:STACEE
Other - Middle Name:
Other - Last Name:GORDON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:5441 S MACADAM AVE STE A
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-6106
Mailing Address - Country:US
Mailing Address - Phone:813-474-6102
Mailing Address - Fax:
Practice Address - Street 1:5441 S MACADAM AVE STE A
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-6106
Practice Address - Country:US
Practice Address - Phone:813-474-6102
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-10
Last Update Date:2025-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORR10411101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health