Provider Demographics
NPI:1205365707
Name:MIRON, STACEY
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:MIRON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:STACEY
Other - Middle Name:
Other - Last Name:GLAESS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:15250 HOMESTEAD AVE N
Mailing Address - Street 2:
Mailing Address - City:HUGO
Mailing Address - State:MN
Mailing Address - Zip Code:55038-9408
Mailing Address - Country:US
Mailing Address - Phone:612-940-9064
Mailing Address - Fax:
Practice Address - Street 1:5200 FAIRVIEW BLVD
Practice Address - Street 2:
Practice Address - City:WYOMING
Practice Address - State:MN
Practice Address - Zip Code:55092-8013
Practice Address - Country:US
Practice Address - Phone:651-982-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-08
Last Update Date:2017-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN10660225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN10660OtherMINNESOTA BOARD OF PHYSICAL THERAPY