Provider Demographics
NPI:1851608749
Name:TKACH, STEPHANIE HYACINTH (LICSW)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:HYACINTH
Last Name:TKACH
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5752 IRVING AVENUE SOUTH
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55419
Mailing Address - Country:US
Mailing Address - Phone:612-558-6760
Mailing Address - Fax:
Practice Address - Street 1:2908 HUMBOLDT AVE S
Practice Address - Street 2:SUITE 6
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55408-1953
Practice Address - Country:US
Practice Address - Phone:612-558-6760
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-13
Last Update Date:2019-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN171171041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical