Provider Demographics
NPI:1558874768
Name:TWEEDT, STACEY LYNN (LADC)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:LYNN
Last Name:TWEEDT
Suffix:
Gender:F
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1119 GRANT ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MN
Mailing Address - Zip Code:56143-1207
Mailing Address - Country:US
Mailing Address - Phone:507-841-2574
Mailing Address - Fax:
Practice Address - Street 1:407 5TH ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MN
Practice Address - Zip Code:56143-1583
Practice Address - Country:US
Practice Address - Phone:507-841-2574
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-09
Last Update Date:2017-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN302628101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty