Individual
STACY ANN WILSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
CRM, QMHA, CADC
Contact information
Practice address
2901 E BURNSIDE ST, PORTLAND, OR 97214-1831
(503) 238-5203
Mailing address
2901 E BURNSIDE ST, PORTLAND, OR 97214-1831
(503) 238-5203
Taxonomy
Speciality
Code
Description
License number
State
101YA0400X
Addiction (Substance Use Disorder) Counselor
Primary
25-03-11415
OR
174400000X
Specialist
24-QMHA-I-004213
OR
175T00000X
Peer Specialist
20-CRM-007
OR
Other
Enumeration date
02/19/2020
Last updated
03/04/2025
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