Provider Demographics
NPI:1457757866
Name:MINKOWSKY, STACY ANN
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:ANN
Last Name:MINKOWSKY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36 MAPLE RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:MONMOUTH
Mailing Address - State:ME
Mailing Address - Zip Code:04259-7330
Mailing Address - Country:US
Mailing Address - Phone:207-754-9883
Mailing Address - Fax:
Practice Address - Street 1:4 PARK ST
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ME
Practice Address - Zip Code:04240-7172
Practice Address - Country:US
Practice Address - Phone:207-784-0922
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-12
Last Update Date:2014-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECAC5722101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)