Provider Demographics
NPI:1093361669
Name:YANEZ, CONNIE
Entity Type:Individual
Prefix:
First Name:CONNIE
Middle Name:
Last Name:YANEZ
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 1:2739 MALLARD DR
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55125-3851
Mailing Address - Country:US
Mailing Address - Phone:218-428-7738
Mailing Address - Fax:
Practice Address - Street 1:14949 62ND ST N
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:MN
Practice Address - Zip Code:55082-6132
Practice Address - Country:US
Practice Address - Phone:651-275-7400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-10
Last Update Date:2019-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health