Healthcare Provider Details

I. General information

NPI: 1669750923
Provider Name (Legal Business Name): STACEY JAE KUHL LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2011
Last Update Date: 08/03/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1125 6TH ST SE
WILLMAR MN
56201-4675
US

IV. Provider business mailing address

1125 6TH ST SE
WILLMAR MN
56201-4675
US

V. Phone/Fax

Practice location:
  • Phone: 320-235-4613
  • Fax:
Mailing address:
  • Phone: 320-235-4613
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number2069
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: