Provider Demographics
NPI:1831539261
Name:BORN, STACI LEIGH (EDD, LMFT, RPT)
Entity type:Individual
Prefix:
First Name:STACI
Middle Name:LEIGH
Last Name:BORN
Suffix:
Gender:F
Credentials:EDD, LMFT, RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 WAYNESBOROUGH WAY
Mailing Address - Street 2:
Mailing Address - City:MANKATO
Mailing Address - State:MN
Mailing Address - Zip Code:56001-6457
Mailing Address - Country:US
Mailing Address - Phone:507-380-0626
Mailing Address - Fax:
Practice Address - Street 1:108 WAYNESBOROUGH WAY
Practice Address - Street 2:
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56001-6457
Practice Address - Country:US
Practice Address - Phone:507-380-0626
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-29
Last Update Date:2022-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
SDLMFT1230106H00000X
MN2566106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor