Provider Demographics
NPI:1003917543
Name:MISKIMEN, STACI LYNN (MSW)
Entity Type:Individual
Prefix:MRS
First Name:STACI
Middle Name:LYNN
Last Name:MISKIMEN
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 VETERANS DR
Mailing Address - Street 2:ROUTING: 116A
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55417-2309
Mailing Address - Country:US
Mailing Address - Phone:612-467-4022
Mailing Address - Fax:612-725-2139
Practice Address - Street 1:1 VETERANS DR
Practice Address - Street 2:ROUTING: 116A
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55417-2309
Practice Address - Country:US
Practice Address - Phone:612-467-4022
Practice Address - Fax:612-725-2139
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN178011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical