Provider Demographics
NPI:1336385871
Name:HANSEN, STACEY MAE (LMFT)
Entity type:Individual
Prefix:MRS
First Name:STACEY
Middle Name:MAE
Last Name:HANSEN
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:925 SULLIVAN AVE
Mailing Address - Street 2:UNIT 2
Mailing Address - City:SOUTH WINDSOR
Mailing Address - State:CT
Mailing Address - Zip Code:06074-2025
Mailing Address - Country:US
Mailing Address - Phone:860-432-7771
Mailing Address - Fax:860-432-7774
Practice Address - Street 1:925 SULLIVAN AVE
Practice Address - Street 2:UNIT 2
Practice Address - City:SOUTH WINDSOR
Practice Address - State:CT
Practice Address - Zip Code:06074-2025
Practice Address - Country:US
Practice Address - Phone:860-432-7771
Practice Address - Fax:860-432-7774
Is Sole Proprietor?:No
Enumeration Date:2009-01-06
Last Update Date:2015-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001227106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008025577Medicaid