Provider Demographics
NPI:1467894105
Name:STUCKY, GARY EDWARD (MA/LP)
Entity Type:Individual
Prefix:MR
First Name:GARY
Middle Name:EDWARD
Last Name:STUCKY
Suffix:
Gender:M
Credentials:MA/LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 DECATUR AVE N
Mailing Address - Street 2:SUITE 109
Mailing Address - City:GOLDEN VALLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55427-4367
Mailing Address - Country:US
Mailing Address - Phone:763-746-2400
Mailing Address - Fax:763-746-2401
Practice Address - Street 1:701 DECATUR AVE N
Practice Address - Street 2:SUITE 109
Practice Address - City:GOLDEN VALLEY
Practice Address - State:MN
Practice Address - Zip Code:55427-4367
Practice Address - Country:US
Practice Address - Phone:763-746-2400
Practice Address - Fax:763-746-2401
Is Sole Proprietor?:No
Enumeration Date:2013-07-23
Last Update Date:2013-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1575103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling