Healthcare Provider Details

I. General information

NPI: 1417595315
Provider Name (Legal Business Name): STACY L OLMSCHEID
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/11/2019
Last Update Date: 12/11/2019
Certification Date: 12/11/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 14TH AVE E
SARTELL MN
56377
US

IV. Provider business mailing address

108 DOCTORS PARK
SAINT CLOUD MN
56303
US

V. Phone/Fax

Practice location:
  • Phone:
  • Fax:
Mailing address:
  • Phone: 320-774-3915
  • Fax: 320-774-3918

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: