Provider Demographics
NPI:1912605437
Name:STACEY, TAMMEY JO (LADC)
Entity Type:Individual
Prefix:
First Name:TAMMEY
Middle Name:JO
Last Name:STACEY
Suffix:
Gender:F
Credentials:LADC
Other - Prefix:
Other - First Name:TAMMEY
Other - Middle Name:JO
Other - Last Name:MALMSKOG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LADC
Mailing Address - Street 1:22690 GOOSE DR
Mailing Address - Street 2:
Mailing Address - City:AKELEY
Mailing Address - State:MN
Mailing Address - Zip Code:56433-8027
Mailing Address - Country:US
Mailing Address - Phone:218-255-4109
Mailing Address - Fax:
Practice Address - Street 1:22690 GOOSE DR
Practice Address - Street 2:
Practice Address - City:AKELEY
Practice Address - State:MN
Practice Address - Zip Code:56433-8027
Practice Address - Country:US
Practice Address - Phone:218-255-4109
Practice Address - Fax:218-652-3145
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-23
Last Update Date:2023-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN306539101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)