Provider Demographics
NPI:1437895380
Name:RUSTMAN, STACEY CHRISTINE
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:CHRISTINE
Last Name:RUSTMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5868 BAKER RD
Mailing Address - Street 2:
Mailing Address - City:MINNETONKA
Mailing Address - State:MN
Mailing Address - Zip Code:55345-5903
Mailing Address - Country:US
Mailing Address - Phone:952-767-4200
Mailing Address - Fax:
Practice Address - Street 1:2101 ROLLING GREEN LN
Practice Address - Street 2:
Practice Address - City:NORTH MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56003-4442
Practice Address - Country:US
Practice Address - Phone:952-767-4200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-12
Last Update Date:2022-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst