Provider Demographics
NPI:1912475310
Name:BURRELL, STACY LYNN (LADC)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:LYNN
Last Name:BURRELL
Suffix:
Gender:F
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:37863 186TH AVE
Mailing Address - Street 2:
Mailing Address - City:AVON
Mailing Address - State:MN
Mailing Address - Zip Code:56310-8704
Mailing Address - Country:US
Mailing Address - Phone:320-237-0688
Mailing Address - Fax:
Practice Address - Street 1:1906 5TH AVE SE
Practice Address - Street 2:
Practice Address - City:LITTLE FALLS
Practice Address - State:MN
Practice Address - Zip Code:56345-3317
Practice Address - Country:US
Practice Address - Phone:320-632-6647
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-05
Last Update Date:2018-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN305223101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)