Provider Demographics
NPI:1891862538
Name:STAHLE, REBECCA L (LICSW)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:L
Last Name:STAHLE
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 1:18300 MTKA BLVD., STE 210
Mailing Address - Street 2:
Mailing Address - City:DEEPHAVEN
Mailing Address - State:MN
Mailing Address - Zip Code:55391-3272
Mailing Address - Country:US
Mailing Address - Phone:952-404-9124
Mailing Address - Fax:952-404-9273
Practice Address - Street 1:18300 MTKA BLVD., STE 210
Practice Address - Street 2:
Practice Address - City:DEEPHAVEN
Practice Address - State:MN
Practice Address - Zip Code:55391-3272
Practice Address - Country:US
Practice Address - Phone:952-404-9124
Practice Address - Fax:952-404-9273
Is Sole Proprietor?:No
Enumeration Date:2006-11-29
Last Update Date:2010-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN130151041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN510640100Medicaid
MN510640100Medicaid