MEDICARE: STACY RENAE HAINE LMHC, BCABA, NCC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	MH7446	FL
2	103K00000X	Behavior Analyst	0-00-0076

General Provider Information

NPI Number	:	1013232057
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STACY RENAE HAINE LMHC, BCABA, NCC

Provider Business Mailing Address
First Line	:	3068 SANTEE PL
Second Line	:
City	:	SAINT JOHNS
State	:	FL
Zip	:	32259-2137
Country	:	US
Telephone Number	:	904-728-1156
Fax Number	:

Provider Business Practice Location Address
First Line	:	519 N NEWNAN ST
Second Line	:	SUITE 2
City	:	JACKSONVILLE
State	:	FL
Zip	:	32202-3121
Country	:	US
Telephone Number	:	904-728-1156
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/01/2010
Last Update Date	:	01/17/2012

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