Provider Demographics
NPI:1356473409
Name:SLAUGHTER, STACY L (PSY D)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:L
Last Name:SLAUGHTER
Suffix:
Gender:F
Credentials:PSY D
Other - Prefix:
Other - First Name:STACY
Other - Middle Name:L
Other - Last Name:FULLER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PSY D
Mailing Address - Street 1:1015 S BROADWAY STE 18
Mailing Address - Street 2:
Mailing Address - City:MINOT
Mailing Address - State:ND
Mailing Address - Zip Code:58701-4667
Mailing Address - Country:US
Mailing Address - Phone:701-857-8500
Mailing Address - Fax:701-857-8555
Practice Address - Street 1:1015 S BROADWAY STE 18
Practice Address - Street 2:
Practice Address - City:MINOT
Practice Address - State:ND
Practice Address - Zip Code:58701-4667
Practice Address - Country:US
Practice Address - Phone:701-857-8500
Practice Address - Fax:701-857-8555
Is Sole Proprietor?:No
Enumeration Date:2007-03-12
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND404103T00000X
ND171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND029122OtherBLUE CROSS BLUE SHIELD
ND054517Medicaid
ND$$$$$$$$$OtherCHAMPUS/CHAMPUSVA
ND054517Medicaid