Provider Demographics
NPI:1679369938
Name:NATHAN, STACY
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:NATHAN
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10755 93RD AVE N
Mailing Address - Street 2:
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55369-4109
Mailing Address - Country:US
Mailing Address - Phone:612-597-0675
Mailing Address - Fax:
Practice Address - Street 1:8060 HWY 55 STE 100
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:MN
Practice Address - Zip Code:55373-9407
Practice Address - Country:US
Practice Address - Phone:612-597-0675
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-15
Last Update Date:2025-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)