Provider Demographics
NPI:1275856692
Name:PROULX, STACY A (MA, LAMFT)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:A
Last Name:PROULX
Suffix:
Gender:F
Credentials:MA, LAMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6607 18TH AVE S
Mailing Address - Street 2:SUITE 201
Mailing Address - City:RICHFIELD
Mailing Address - State:MN
Mailing Address - Zip Code:55423-2784
Mailing Address - Country:US
Mailing Address - Phone:612-455-4040
Mailing Address - Fax:612-455-4041
Practice Address - Street 1:6607 18TH AVE S
Practice Address - Street 2:SUITE 201
Practice Address - City:RICHFIELD
Practice Address - State:MN
Practice Address - Zip Code:55423-2784
Practice Address - Country:US
Practice Address - Phone:612-455-4040
Practice Address - Fax:612-455-4041
Is Sole Proprietor?:No
Enumeration Date:2010-03-12
Last Update Date:2010-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2107106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist