Provider Demographics
NPI:1477073179
Name:FOSENBURG, STACI LYNN (PHD)
Entity Type:Individual
Prefix:
First Name:STACI
Middle Name:LYNN
Last Name:FOSENBURG
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 UNIVERSITY AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50314-2355
Mailing Address - Country:US
Mailing Address - Phone:515-248-1447
Mailing Address - Fax:515-248-1440
Practice Address - Street 1:3509 E 29TH ST
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50317-4253
Practice Address - Country:US
Practice Address - Phone:515-248-1600
Practice Address - Fax:515-248-1610
Is Sole Proprietor?:No
Enumeration Date:2017-06-23
Last Update Date:2023-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA103T00000X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist