Provider Demographics
NPI:1114119179
Name:GORMAN, STACY (MS, LPC-MH)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:GORMAN
Suffix:
Gender:F
Credentials:MS, LPC-MH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 9191
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55480-9191
Mailing Address - Country:US
Mailing Address - Phone:605-322-6428
Mailing Address - Fax:605-322-6499
Practice Address - Street 1:2412 S CLIFF AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57105-4031
Practice Address - Country:US
Practice Address - Phone:605-322-4079
Practice Address - Fax:605-322-4080
Is Sole Proprietor?:No
Enumeration Date:2007-08-14
Last Update Date:2010-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD06111289101YA0400X
SDLPC-MH2172101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD6576790Medicaid
9287682OtherDAKOTACARE