Provider Demographics
NPI:1033758537
Name:HAGGERTY, STACY
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:HAGGERTY
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 1:6308 HILLCREST RD
Mailing Address - Street 2:
Mailing Address - City:CARY
Mailing Address - State:IL
Mailing Address - Zip Code:60013-1350
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:25 N RIVER LN STE 2109
Practice Address - Street 2:
Practice Address - City:GENEVA
Practice Address - State:IL
Practice Address - Zip Code:60134-2003
Practice Address - Country:US
Practice Address - Phone:331-263-6093
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-31
Last Update Date:2023-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RBT-15-07200106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician