| Doctor Name: | STACIE MARIE HETTINGA |
| NPI Number: | 1386836310 |
| Entity Type Code: | Individual (1) |
| Gender: | F |
| Credentials: | LCPC |
| License Number: | LCPC3712 |
| Business Practice Address: | 205 N Berkley Council, ID - 83612 |
| Business Phone Number: | 2082536850 |
| Business Fax Number: | 2082536849 |
| Mailing Address: | Po Box 428, COUNCIL |
| State: | ID |
| Postal Code: | 83612 |
| Phone Number: | 2082534242 |
| Fax Number: | 2082536849 |
| NPI Enumeration Date: | 08/14/2007 |
| NPI Last Update Date: | 08/14/2007 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 101YP2500X |
| License Number: | LCPC3712 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | ID |
| Taxonomy Type: | Behavioral Health & Social Service Providers |
| Taxonomy Classification: | Counselor |
| Taxonomy Specialization: | Professional |
| Taxonomy Definition: | |