Provider Demographics
NPI:1427104280
Name:GERKEN, STACEY (PHD, LP)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:GERKEN
Suffix:
Gender:F
Credentials:PHD, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:608 RONELL ST
Mailing Address - Street 2:
Mailing Address - City:SAINT PETER
Mailing Address - State:MN
Mailing Address - Zip Code:56082-1939
Mailing Address - Country:US
Mailing Address - Phone:507-931-1040
Mailing Address - Fax:
Practice Address - Street 1:116 S 3RD ST
Practice Address - Street 2:
Practice Address - City:SAINT PETER
Practice Address - State:MN
Practice Address - Zip Code:56082-2043
Practice Address - Country:US
Practice Address - Phone:507-931-8040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP4430103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNHP47857OtherHEALTH PARTNERS INDIV #
MN113172OtherUCARE INDIVIDUAL #
MN287P7GEOtherBCBS INDIVIDUAL #