Healthcare Provider Details

I. General information

NPI: 1063354660
Provider Name (Legal Business Name): STACEY COWAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2026
Last Update Date: 08/18/2026
Certification Date: 08/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9120 SPRINGBROOK DR NW
COON RAPIDS MN
55433-5845
US

IV. Provider business mailing address

9120 SPRINGBROOK DR NW
COON RAPIDS MN
55433-5845
US

V. Phone/Fax

Practice location:
  • Phone: 763-231-2590
  • Fax:
Mailing address:
  • Phone: 763-231-2590
  • Fax: 763-231-2590

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number104700
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: