Provider Demographics
NPI:1275275026
Name:HERDEGEN, STACEY (LMFT, NCC)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:HERDEGEN
Suffix:
Gender:F
Credentials:LMFT, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:408 N SUMMERLIN AVE
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32803-5338
Mailing Address - Country:US
Mailing Address - Phone:941-323-7007
Mailing Address - Fax:
Practice Address - Street 1:408 N SUMMERLIN AVE
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32803-5338
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:2024-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMT4854101Y00000X, 106H00000X
FLIMT3648106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor