Provider Demographics
NPI:1457723769
Name:GUSTAFSON, STACY LOUISE (LPCC)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:LOUISE
Last Name:GUSTAFSON
Suffix:
Gender:F
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14639 WHITEBIRCH LN
Mailing Address - Street 2:PO BOX 625
Mailing Address - City:CROSSLAKE
Mailing Address - State:MN
Mailing Address - Zip Code:56442-3074
Mailing Address - Country:US
Mailing Address - Phone:218-821-5064
Mailing Address - Fax:
Practice Address - Street 1:980 1ST ST N
Practice Address - Street 2:
Practice Address - City:PINE RIVER
Practice Address - State:MN
Practice Address - Zip Code:56474-4508
Practice Address - Country:US
Practice Address - Phone:218-587-8036
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-26
Last Update Date:2015-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNCC1066101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health