Healthcare Provider Details

I. General information

NPI: 1932872199
Provider Name (Legal Business Name): STACEY KRUEGER LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/25/2021
Last Update Date: 05/27/2026
Certification Date: 05/27/2026
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 NumberLPC-22793
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: