Provider Demographics
NPI:1003120395
Name:STAUFFER, IVA JOAN (LICSW)
Entity Type:Individual
Prefix:
First Name:IVA
Middle Name:JOAN
Last Name:STAUFFER
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2021 E HENNEPIN AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55413-2700
Mailing Address - Country:US
Mailing Address - Phone:612-617-7802
Mailing Address - Fax:612-331-6772
Practice Address - Street 1:5905 GOLDEN VALLEY RD
Practice Address - Street 2:SUITE 100
Practice Address - City:GOLDEN VALLEY
Practice Address - State:MN
Practice Address - Zip Code:55422-4463
Practice Address - Country:US
Practice Address - Phone:612-617-7802
Practice Address - Fax:612-331-6772
Is Sole Proprietor?:No
Enumeration Date:2010-07-29
Last Update Date:2010-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN192931041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical