Provider Demographics
NPI:1518591718
Name:HASELHORST, STACEY
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:HASELHORST
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 1:1733 NE DUCHESS DR
Mailing Address - Street 2:
Mailing Address - City:LEES SUMMIT
Mailing Address - State:MO
Mailing Address - Zip Code:64086-6244
Mailing Address - Country:US
Mailing Address - Phone:816-839-1780
Mailing Address - Fax:
Practice Address - Street 1:668 SE BAYBERRY LN STE 101
Practice Address - Street 2:
Practice Address - City:LEES SUMMIT
Practice Address - State:MO
Practice Address - Zip Code:64063-4366
Practice Address - Country:US
Practice Address - Phone:816-260-6982
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-26
Last Update Date:2020-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2020003835101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional