Provider Demographics
NPI:1417728791
Name:STEIN, EMERSON CEE KENNEDY
Entity type:Individual
Prefix:
First Name:EMERSON
Middle Name:CEE KENNEDY
Last Name:STEIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:CASSANDRA KATHLYNN
Other - Last Name:FERGUSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1011 MEADOWLANDS DR STE 1&2
Mailing Address - Street 2:
Mailing Address - City:WHITE BEAR LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55127-2339
Mailing Address - Country:US
Mailing Address - Phone:612-445-0302
Mailing Address - Fax:
Practice Address - Street 1:1011 MEADOWLANDS DR STE 1&2
Practice Address - Street 2:
Practice Address - City:WHITE BEAR LAKE
Practice Address - State:MN
Practice Address - Zip Code:55127-2339
Practice Address - Country:US
Practice Address - Phone:612-445-0302
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-15
Last Update Date:2024-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician