Provider Demographics
NPI:1760790828
Name:NELSON, STACEY LYNN (PSYD)
Entity Type:Individual
Prefix:DR
First Name:STACEY
Middle Name:LYNN
Last Name:NELSON
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:STACEY
Other - Middle Name:LYNN
Other - Last Name:ALLEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PSYD
Mailing Address - Street 1:19230 EVANS ST NW STE 109
Mailing Address - Street 2:
Mailing Address - City:ELK RIVER
Mailing Address - State:MN
Mailing Address - Zip Code:55330-1079
Mailing Address - Country:US
Mailing Address - Phone:952-213-5648
Mailing Address - Fax:763-400-7444
Practice Address - Street 1:19230 EVANS ST NW STE 109
Practice Address - Street 2:
Practice Address - City:ELK RIVER
Practice Address - State:MN
Practice Address - Zip Code:55330-1079
Practice Address - Country:US
Practice Address - Phone:952-213-5648
Practice Address - Fax:952-213-5663
Is Sole Proprietor?:No
Enumeration Date:2010-09-22
Last Update Date:2022-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP5661103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN943400400Medicaid
MNH400153967OtherMEDICARE PTAN
MNH400153967Medicare PIN