Provider Demographics
NPI:1013232057
Name:HAINE, STACY RENAE (LMHC, BCABA, NCC)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:RENAE
Last Name:HAINE
Suffix:
Gender:F
Credentials:LMHC, BCABA, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3068 SANTEE PL
Mailing Address - Street 2:
Mailing Address - City:SAINT JOHNS
Mailing Address - State:FL
Mailing Address - Zip Code:32259-2137
Mailing Address - Country:US
Mailing Address - Phone:904-728-1156
Mailing Address - Fax:
Practice Address - Street 1:519 N NEWNAN ST
Practice Address - Street 2:SUITE 2
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32202-3121
Practice Address - Country:US
Practice Address - Phone:904-728-1156
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-01
Last Update Date:2012-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH7446101YM0800X
0-00-0076103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health