Provider Demographics
NPI:1649552415
Name:MEATH, STACEY E (LICSW)
Entity type:Individual
Prefix:MRS
First Name:STACEY
Middle Name:E
Last Name:MEATH
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:STACEY
Other - Middle Name:E
Other - Last Name:GRENZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2705 BUNKER LAKE BLVD NW
Mailing Address - Street 2:SUITE 100
Mailing Address - City:ANDOVER
Mailing Address - State:MN
Mailing Address - Zip Code:55304-3784
Mailing Address - Country:US
Mailing Address - Phone:763-482-9598
Mailing Address - Fax:612-235-6447
Practice Address - Street 1:2705 BUNKER LAKE BLVD NW
Practice Address - Street 2:SUITE 100
Practice Address - City:ANDOVER
Practice Address - State:MN
Practice Address - Zip Code:55304-3784
Practice Address - Country:US
Practice Address - Phone:763-482-9598
Practice Address - Fax:612-235-6447
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-16
Last Update Date:2015-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN164321041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical