Healthcare Provider Details

I. General information

NPI: 1215768528
Provider Name (Legal Business Name): STACEY KRUEGER THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/08/2024
Last Update Date: 06/12/2026
Certification Date: 06/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11811 N TATUM BLVD STE 3031
PHOENIX AZ
85028-1621
US

IV. Provider business mailing address

11811 N TATUM BLVD STE 3031
PHOENIX AZ
85028-1621
US

V. Phone/Fax

Practice location:
  • Phone: 602-492-8948
  • Fax: 480-542-2103
Mailing address:
  • Phone: 602-492-8948
  • Fax: 480-542-2103

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: STACEY KRUEGER
Title or Position: OWNER MANAGER
Credential: LPC
Phone: 602-492-8948