Provider Demographics
NPI:1730297300
Name:ANDERSON, STACIA R (PT)
Entity Type:Individual
Prefix:
First Name:STACIA
Middle Name:R
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:7581 9TH ST N STE 100
Mailing Address - Street 2:
Mailing Address - City:OAKDALE
Mailing Address - State:MN
Mailing Address - Zip Code:55128-6635
Mailing Address - Country:US
Mailing Address - Phone:651-748-4338
Mailing Address - Fax:651-748-2892
Practice Address - Street 1:146 LAKE ST N
Practice Address - Street 2:
Practice Address - City:FOREST LAKE
Practice Address - State:MN
Practice Address - Zip Code:55025-2518
Practice Address - Country:US
Practice Address - Phone:651-464-8502
Practice Address - Fax:651-464-8547
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2019-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4512225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN195K5ANOtherBLUECROSS BLUESHIELD
MN6400629OtherMEDICA
MN436322100Medicaid
MNHP35860OtherHEALTHPARTNERS