Provider Demographics
NPI:1932642592
Name:KOSKINEN, STACIE M (LPC)
Entity Type:Individual
Prefix:
First Name:STACIE
Middle Name:M
Last Name:KOSKINEN
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:STACIE
Other - Middle Name:M
Other - Last Name:BOEX
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2050 RIVERSIDE DR STE 108
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54301-2364
Mailing Address - Country:US
Mailing Address - Phone:920-259-2307
Mailing Address - Fax:
Practice Address - Street 1:300 CROOKS ST
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301-4527
Practice Address - Country:US
Practice Address - Phone:920-436-6800
Practice Address - Fax:920-432-5966
Is Sole Proprietor?:No
Enumeration Date:2016-11-29
Last Update Date:2023-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3306101Y00000X
WI7709101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1932642592Medicaid