Provider Demographics
NPI:1346399797
Name:LAVES-KHALIFA, STACEY MAUREEN (MED)
Entity Type:Individual
Prefix:MS
First Name:STACEY
Middle Name:MAUREEN
Last Name:LAVES-KHALIFA
Suffix:
Gender:F
Credentials:MED
Other - Prefix:MS
Other - First Name:STACEY
Other - Middle Name:MAUREEN
Other - Last Name:LAVES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPC, LMFT, LCDC
Mailing Address - Street 1:8330 DEBBIE GAY DR
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77040-1502
Mailing Address - Country:US
Mailing Address - Phone:281-793-8716
Mailing Address - Fax:
Practice Address - Street 1:3400 BISSONNET ST
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77005-2155
Practice Address - Country:US
Practice Address - Phone:281-793-8716
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX6327101YA0400X
TX10993101YP2500X
TX003603106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Not Answered101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXLP8004396Medicaid
TX156312OtherVALUE OPTIONS