Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 101YM0800X | Mental Health Counselor | MH7446 | FL |
Y | 103K00000X | Behavior Analyst | 0-00-0076 |
NPI | 1013232057 |
---|---|
Provider Name | Stacy Renae Haine |
First Address | Saint Johns, FL 32259-2137 |
Second Address | Jacksonville, FL 32202-3121 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 01/04/2010 |
Last Update Date | 17/01/2012 |