Provider Demographics
NPI:1821489444
Name:HUSEBO, STACY M
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:M
Last Name:HUSEBO
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 1:2637 27TH AVE S STE 16
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55406-1565
Mailing Address - Country:US
Mailing Address - Phone:612-702-2955
Mailing Address - Fax:
Practice Address - Street 1:2637 27TH AVE S STE 16
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55406-1565
Practice Address - Country:US
Practice Address - Phone:612-702-2955
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-18
Last Update Date:2015-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN160341041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical