Healthcare Provider Details

I. General information

NPI: 1811717606
Provider Name (Legal Business Name): ANDREW STOCKMAN LPCC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/15/2024
Last Update Date: 10/15/2024
Certification Date: 10/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2430 NICOLLET AVE
MINNEAPOLIS MN
55404-3461
US

IV. Provider business mailing address

13217 UPTON AVE S
BURNSVILLE MN
55337-2159
US

V. Phone/Fax

Practice location:
  • Phone: 612-871-7443
  • Fax: 612-871-0194
Mailing address:
  • Phone: 320-250-9880
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number4574
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: