Provider Demographics
NPI:1659664209
Name:GILQUIST, STEPHANIE OREEN (LADC)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:OREEN
Last Name:GILQUIST
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 1:11400 JULIANNE AVE N
Mailing Address - Street 2:
Mailing Address - City:STILLWATER
Mailing Address - State:MN
Mailing Address - Zip Code:55082-9436
Mailing Address - Country:US
Mailing Address - Phone:651-426-3300
Mailing Address - Fax:651-426-0419
Practice Address - Street 1:11400 JULIANNE AVE N
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:MN
Practice Address - Zip Code:55082-9436
Practice Address - Country:US
Practice Address - Phone:651-426-3300
Practice Address - Fax:651-426-0419
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-16
Last Update Date:2011-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN301918101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN301918OtherBOARD OF BEHAVIORAL HEALTH AND THERAPY