Provider Demographics
NPI:1275275026
Name:HERDEGEN, STACEY (IMT3648, CFRA)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:HERDEGEN
Suffix:
Gender:F
Credentials:IMT3648, CFRA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1275 LAKE SHADOW CIR APT 13106
Mailing Address - Street 2:
Mailing Address - City:MAITLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32751-7597
Mailing Address - Country:US
Mailing Address - Phone:941-323-7007
Mailing Address - Fax:
Practice Address - Street 1:1275 LAKE SHADOW CIR APT 13106
Practice Address - Street 2:
Practice Address - City:MAITLAND
Practice Address - State:FL
Practice Address - Zip Code:32751-7597
Practice Address - Country:US
Practice Address - Phone:941-323-7007
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-12
Last Update Date:2022-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMT3648101Y00000X, 390200000X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program