Provider Demographics
NPI:1174982615
Name:HAECKER, KATHY DAVIS (LPC)
Entity type:Individual
Prefix:MRS
First Name:KATHY
Middle Name:DAVIS
Last Name:HAECKER
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:MRS
Other - First Name:KATHY
Other - Middle Name:FERN
Other - Last Name:HAECKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPC
Mailing Address - Street 1:403 JOHN VERNON LN
Mailing Address - Street 2:
Mailing Address - City:EULESS
Mailing Address - State:TX
Mailing Address - Zip Code:76040-4723
Mailing Address - Country:US
Mailing Address - Phone:817-247-0608
Mailing Address - Fax:817-571-4117
Practice Address - Street 1:209 N INDUSTRIAL BLVD
Practice Address - Street 2:SUITE 237
Practice Address - City:BEDFORD
Practice Address - State:TX
Practice Address - Zip Code:76021-6128
Practice Address - Country:US
Practice Address - Phone:817-571-4110
Practice Address - Fax:817-571-4117
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-12
Last Update Date:2016-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX67516101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional