Provider Demographics
NPI:1861257685
Name:HOSTETTER, STACEY CLARE
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:CLARE
Last Name:HOSTETTER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1818 243RD AVE NW
Mailing Address - Street 2:
Mailing Address - City:SAINT FRANCIS
Mailing Address - State:MN
Mailing Address - Zip Code:55070-8777
Mailing Address - Country:US
Mailing Address - Phone:763-232-6587
Mailing Address - Fax:
Practice Address - Street 1:11660 ROUND LAKE BLVD NW
Practice Address - Street 2:
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55433-2638
Practice Address - Country:US
Practice Address - Phone:763-767-3350
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-20
Last Update Date:2024-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNNA103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical