Provider Demographics
NPI:1477659118
Name:GRECO, STACY OPAL RANKIN (LICSW)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:OPAL RANKIN
Last Name:GRECO
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:STACY
Other - Middle Name:
Other - Last Name:RANKIN GRECO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LICSW
Mailing Address - Street 1:3005 JAMES AVE S STE 102
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55408-2590
Mailing Address - Country:US
Mailing Address - Phone:612-388-3791
Mailing Address - Fax:
Practice Address - Street 1:3005 JAMES AVE S STE 102
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55408-2590
Practice Address - Country:US
Practice Address - Phone:612-388-3791
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2022-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN148141041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN664425200Medicaid
MN664425200Medicaid