Provider Demographics
NPI:1932200334
Name:FUHRER, STACEY (MPT)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:FUHRER
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:STACEY
Other - Middle Name:
Other - Last Name:GOODMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:13140 150TH AVE SE
Mailing Address - Street 2:
Mailing Address - City:SAINT HILAIRE
Mailing Address - State:MN
Mailing Address - Zip Code:56754-9777
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3001 SANFORD PKWY
Practice Address - Street 2:
Practice Address - City:THIEF RIVER FALLS
Practice Address - State:MN
Practice Address - Zip Code:56701-2700
Practice Address - Country:US
Practice Address - Phone:218-683-4492
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2018-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN6862225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN357T4FUOtherBCBS
MN6404188OtherMEDICA
MN616055700Medicaid