Provider Demographics
NPI:1346576444
Name:BISHOFSKY, STACEY NICOLE (LICSW)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:NICOLE
Last Name:BISHOFSKY
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2925 CHICAGO AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55407-1321
Mailing Address - Country:US
Mailing Address - Phone:612-262-9000
Mailing Address - Fax:
Practice Address - Street 1:7590 LYRIC LN NE
Practice Address - Street 2:
Practice Address - City:FRIDLEY
Practice Address - State:MN
Practice Address - Zip Code:55432-3251
Practice Address - Country:US
Practice Address - Phone:763-236-4300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-23
Last Update Date:2023-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN19606104100000X, 1041C0700X
WI127698-121104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker