Healthcare Provider Details

I. General information

NPI: 1982425500
Provider Name (Legal Business Name): STACEY HACKER LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2024
Last Update Date: 10/17/2024
Certification Date: 10/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

970 EXECUTIVE PARKWAY DR
SAINT LOUIS MO
63141-6302
US

IV. Provider business mailing address

970 EXECUTIVE PARKWAY DR
SAINT LOUIS MO
63141-6302
US

V. Phone/Fax

Practice location:
  • Phone: 314-628-6500
  • Fax:
Mailing address:
  • Phone: 314-628-6500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number2006009231
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: