Individual
STALEY WOOD MIMS III
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
QMHP MED
Contact information
Practice address
2330 NE SISKIYOU ST, PORTLAND, OR 97212-2471
(503) 528-0757
(503) 528-0764
Mailing address
3602 SE 28TH PL APT 15, PORTLAND, OR 97202-3070
(503) 771-0968
Taxonomy
Speciality
Code
Description
License number
State
101YM0800X
Mental Health Counselor
—
—
372600000X
Adult Companion
Primary
—
—
Other
Enumeration date
01/30/2007
Last updated
09/11/2025
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