Provider Demographics
NPI:1588844898
Name:JOHNSON, STACY RYAN (BS)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:RYAN
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:BS
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:2115 COUNTY ROAD D E
Mailing Address - Street 2:SUITE B
Mailing Address - City:MAPLEWOOD
Mailing Address - State:MN
Mailing Address - Zip Code:55109-5353
Mailing Address - Country:US
Mailing Address - Phone:651-748-5019
Mailing Address - Fax:651-773-7591
Practice Address - Street 1:7527 MITCHELL ROAD
Practice Address - Street 2:100
Practice Address - City:EDEN PRAIRIE
Practice Address - State:MN
Practice Address - Zip Code:55344
Practice Address - Country:US
Practice Address - Phone:952-228-2282
Practice Address - Fax:952-224-2284
Is Sole Proprietor?:No
Enumeration Date:2007-11-05
Last Update Date:2024-04-25
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MN2290101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health