Healthcare Provider Details

I. General information

NPI: 1760790828
Provider Name (Legal Business Name): STACEY LYNN NELSON PSY.D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: STACEY LYNN ALLEN PSY.D

II. Dates (important events)

Enumeration Date: 09/22/2010
Last Update Date: 12/30/2022
Certification Date: 12/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19230 EVANS ST NW STE 109
ELK RIVER MN
55330-1079
US

IV. Provider business mailing address

19230 EVANS ST NW STE 109
ELK RIVER MN
55330-1079
US

V. Phone/Fax

Practice location:
  • Phone: 952-213-5648
  • Fax: 952-213-5663
Mailing address:
  • Phone: 952-213-5648
  • Fax: 763-400-7444

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberLP5661
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: