Provider Demographics
NPI:1225087497
Name:STAFFORD, LYNNE M (PSYD, LP)
Entity Type:Individual
Prefix:
First Name:LYNNE
Middle Name:M
Last Name:STAFFORD
Suffix:
Gender:F
Credentials:PSYD, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2925 CHICAGO AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55407-1321
Mailing Address - Country:US
Mailing Address - Phone:612-262-4813
Mailing Address - Fax:612-262-4194
Practice Address - Street 1:4300 EDGEWOOD DR NE
Practice Address - Street 2:
Practice Address - City:SAINT MICHAEL
Practice Address - State:MN
Practice Address - Zip Code:55376-4588
Practice Address - Country:US
Practice Address - Phone:763-744-4000
Practice Address - Fax:763-744-4124
Is Sole Proprietor?:No
Enumeration Date:2006-05-08
Last Update Date:2021-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP4222103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN670914100Medicaid
680001536Medicare ID - Type Unspecified
MN670914100Medicaid