Basic Information
| Provider Information | |||||||||
| NPI: | 1730297300 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ANDERSON | ||||||||
| FirstName: | STACIA | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7581 9TH ST N STE 100 | ||||||||
| Address2: | |||||||||
| City: | OAKDALE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551286635 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6517484338 | ||||||||
| FaxNumber: | 6517482892 | ||||||||
| Practice Location | |||||||||
| Address1: | 146 LAKE ST N | ||||||||
| Address2: | |||||||||
| City: | FOREST LAKE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 550252518 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6514648502 | ||||||||
| FaxNumber: | 6514648547 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/25/2006 | ||||||||
| LastUpdateDate: | 08/23/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 4512 | MN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 195K5AN | 01 | MN | BLUECROSS BLUESHIELD | OTHER | 6400629 | 01 | MN | MEDICA | OTHER | 436322100 | 05 | MN | MEDICAID | HP35860 | 01 | MN | HEALTHPARTNERS | OTHER |