Provider Demographics
NPI:1871064618
Name:WENZEL, STACEY A
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:A
Last Name:WENZEL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17020 SW UPPER BOONES FERRY RD., SUITE 201
Mailing Address - Street 2:
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97224
Mailing Address - Country:US
Mailing Address - Phone:503-894-1539
Mailing Address - Fax:503-210-1453
Practice Address - Street 1:17020 SW UPPER BOONES FERRY RD.,SUITE 201
Practice Address - Street 2:
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97224
Practice Address - Country:US
Practice Address - Phone:503-894-1539
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-05
Last Update Date:2018-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR16420235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist