Provider Demographics
NPI:1992969323
Name:EKBLAD, STACI LYNN (LAPC)
Entity type:Individual
Prefix:MRS
First Name:STACI
Middle Name:LYNN
Last Name:EKBLAD
Suffix:
Gender:F
Credentials:LAPC
Other - Prefix:MISS
Other - First Name:STACI
Other - Middle Name:LYNN
Other - Last Name:SHUMAKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:316 2ND AVE W
Mailing Address - Street 2:
Mailing Address - City:WILLISTON
Mailing Address - State:ND
Mailing Address - Zip Code:58801-5218
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:316 2ND AVE W
Practice Address - Street 2:
Practice Address - City:WILLISTON
Practice Address - State:ND
Practice Address - Zip Code:58801-5218
Practice Address - Country:US
Practice Address - Phone:701-774-4600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-15
Last Update Date:2008-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND609-7-15-08A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND54516Medicaid