Provider Demographics
NPI:1982192258
Name:ELLMAN, STACY LYNN (LPC)
Entity Type:Individual
Prefix:MRS
First Name:STACY
Middle Name:LYNN
Last Name:ELLMAN
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5851 DULUTH ST STE 306
Mailing Address - Street 2:
Mailing Address - City:GOLDEN VALLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55422-3957
Mailing Address - Country:US
Mailing Address - Phone:612-280-5750
Mailing Address - Fax:
Practice Address - Street 1:5851 DULUTH ST STE 306
Practice Address - Street 2:
Practice Address - City:GOLDEN VALLEY
Practice Address - State:MN
Practice Address - Zip Code:55422-3957
Practice Address - Country:US
Practice Address - Phone:612-280-5750
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-23
Last Update Date:2018-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN02005101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional