Provider Demographics
NPI:1104169754
Name:NELSON, STACIE LYNNE (RN, LAMFT)
Entity type:Individual
Prefix:
First Name:STACIE
Middle Name:LYNNE
Last Name:NELSON
Suffix:
Gender:F
Credentials:RN, LAMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 752
Mailing Address - Street 2:
Mailing Address - City:DELANO
Mailing Address - State:MN
Mailing Address - Zip Code:55328-0752
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:265 RIVER ST N
Practice Address - Street 2:
Practice Address - City:DELANO
Practice Address - State:MN
Practice Address - Zip Code:55328-8266
Practice Address - Country:US
Practice Address - Phone:612-584-1153
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-02
Last Update Date:2013-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2696101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health