Provider Demographics
NPI:1689143380
Name:GULLICKSON, STEPHANIE CAROLYN
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:CAROLYN
Last Name:GULLICKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8200 HUMBOLDT AVE S STE 306
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55431-1453
Mailing Address - Country:US
Mailing Address - Phone:952-236-7891
Mailing Address - Fax:952-426-4935
Practice Address - Street 1:8200 HUMBOLDT AVE S STE 306
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55431-1453
Practice Address - Country:US
Practice Address - Phone:952-236-7891
Practice Address - Fax:952-426-4935
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-26
Last Update Date:2018-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty