=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558874768
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | STACEY LYNN TWEEDT LADC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/09/2017
-----------------------------------------------------
Last Update Date | 10/10/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1119 GRANT ST
-----------------------------------------------------
City | JACKSON
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 56143-1207
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 507-407-2177
-----------------------------------------------------
Fax | 507-540-1135
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1119 GRANT ST
-----------------------------------------------------
City | JACKSON
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 56143-1207
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 507-841-2574
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | 302628
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 4087
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------