Provider Demographics
NPI:1093476632
Name:LILLEBO-MILLER, STACEY (LICSW)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:LILLEBO-MILLER
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:STACEY
Other - Middle Name:
Other - Last Name:LILLEBO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LICSW
Mailing Address - Street 1:6908 10TH AVE S
Mailing Address - Street 2:
Mailing Address - City:RICHFIELD
Mailing Address - State:MN
Mailing Address - Zip Code:55423-2503
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9055 SPRINGBROOK DR NW
Practice Address - Street 2:
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55433-5841
Practice Address - Country:US
Practice Address - Phone:763-780-9155
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-05
Last Update Date:2022-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN268501041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical