MEDICARE: STACEY HERDEGEN LMFT, 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	101Y00000X	Counselor	MT4854	FL
2	106H00000X	Marriage & Family Therapist	MT4854	FL

General Provider Information

NPI Number	:	1275275026
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STACEY HERDEGEN LMFT, NCC

Provider Business Mailing Address
First Line	:	408 N SUMMERLIN AVE
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32803-5338
Country	:	US
Telephone Number	:	941-323-7007
Fax Number	:

Provider Business Practice Location Address
First Line	:	408 N SUMMERLIN AVE
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32803-5338
Country	:	US
Telephone Number	:	941-323-7007
Fax Number	:

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

Provider Enumeration Date	:	04/12/2022
Last Update Date	:	09/24/2024

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