Provider Demographics
NPI:1295970986
Name:NISSEN, STACIA MARIE (MA, LPC-MH, LAC, NCC)
Entity type:Individual
Prefix:
First Name:STACIA
Middle Name:MARIE
Last Name:NISSEN
Suffix:
Gender:F
Credentials:MA, LPC-MH, LAC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:711 N LAKE AVE
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57104-2203
Mailing Address - Country:US
Mailing Address - Phone:605-339-0420
Mailing Address - Fax:605-339-0420
Practice Address - Street 1:711 N LAKE AVE
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57104-2203
Practice Address - Country:US
Practice Address - Phone:605-339-0420
Practice Address - Fax:605-339-0038
Is Sole Proprietor?:No
Enumeration Date:2008-12-09
Last Update Date:2018-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD08111384101YA0400X
SDLPC-MH20292101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)