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NPI Code Detail

MEDICARE: MRS. STACEY ANN BERENT PROVISIONAL LICSW

MEDICARE: MRS. STACEY ANN BERENT PROVISIONAL LICSW
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
11041C0700XClinical Social Worker24833MN

General Provider Information

NPI Number : 1790620524
Entity Type Code : Individual
Provider Name (Legal Business Name) : MRS. STACEY ANN BERENT PROVISIONAL LICSW
Provider Business Mailing Address
First Line : 11857 MAPLEWOOD DR
Second Line :
City : BRAINERD
State : MN
Zip : 56401-2388
Country : US
Telephone Number : 218-831-1002
Fax Number :
Provider Business Practice Location Address
First Line : 823 MAPLE ST
Second Line :
City : BRAINERD
State : MN
Zip : 56401-3770
Country : US
Telephone Number : 218-454-8001
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 04/20/2026
Last Update Date : 04/20/2026

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Directions to “ MRS. STACEY ANN BERENT PROVISIONAL LICSW” Practice Location

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