Provider Demographics
NPI:1265970537
Name:BARKER, STACIE
Entity type:Individual
Prefix:
First Name:STACIE
Middle Name:
Last Name:BARKER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3030 GRANADA AVE N
Mailing Address - Street 2:SUITE B
Mailing Address - City:OAKDALE
Mailing Address - State:MN
Mailing Address - Zip Code:55128-3543
Mailing Address - Country:US
Mailing Address - Phone:651-209-1111
Mailing Address - Fax:651-779-7896
Practice Address - Street 1:3030 GRANADA AVE N
Practice Address - Street 2:SUITE B
Practice Address - City:OAKDALE
Practice Address - State:MN
Practice Address - Zip Code:55128-3543
Practice Address - Country:US
Practice Address - Phone:651-209-1111
Practice Address - Fax:651-779-7896
Is Sole Proprietor?:No
Enumeration Date:2017-02-07
Last Update Date:2017-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN10847801HCBS171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor