Provider Demographics
NPI:1174712830
Name:HAUCK KHANNA, STACEY (LCSW)
Entity type:Individual
Prefix:MRS
First Name:STACEY
Middle Name:
Last Name:HAUCK KHANNA
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:STACEY
Other - Middle Name:HAUCK
Other - Last Name:KHANNA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:2918 N PINE HILLS RD
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32808-3504
Mailing Address - Country:US
Mailing Address - Phone:407-443-2108
Mailing Address - Fax:
Practice Address - Street 1:2918 N PINE HILLS RD
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32808-3504
Practice Address - Country:US
Practice Address - Phone:407-443-2108
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-18
Last Update Date:2010-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW45191041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical