Provider Demographics
NPI:1386836310
Name:HETTINGA, STACIE MARIE (LCPC)
Entity Type:Individual
Prefix:
First Name:STACIE
Middle Name:MARIE
Last Name:HETTINGA
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 428
Mailing Address - Street 2:
Mailing Address - City:COUNCIL
Mailing Address - State:ID
Mailing Address - Zip Code:83612
Mailing Address - Country:US
Mailing Address - Phone:208-253-4242
Mailing Address - Fax:208-253-6849
Practice Address - Street 1:205 N BERKLEY
Practice Address - Street 2:
Practice Address - City:COUNCIL
Practice Address - State:ID
Practice Address - Zip Code:83612
Practice Address - Country:US
Practice Address - Phone:208-253-6850
Practice Address - Fax:208-253-6849
Is Sole Proprietor?:No
Enumeration Date:2007-08-14
Last Update Date:2007-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCPC3712101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional