Provider Demographics
NPI:1710920608
Name:STILLMAN, JOHN R (LICSW)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:R
Last Name:STILLMAN
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2809 WAYZATA BLVD
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55405-2131
Mailing Address - Country:US
Mailing Address - Phone:612-377-9190
Mailing Address - Fax:612-374-4498
Practice Address - Street 1:2809 WAYZATA BLVD
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55405-2131
Practice Address - Country:US
Practice Address - Phone:612-377-9190
Practice Address - Fax:612-374-4498
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2008-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN127701041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN467821400Medicaid
MN800001461Medicare PIN