Provider Demographics
NPI:1295563658
Name:BETTELON, STACY E (LAC)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:E
Last Name:BETTELON
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 401
Mailing Address - Street 2:
Mailing Address - City:GILSUM
Mailing Address - State:NH
Mailing Address - Zip Code:03448-0401
Mailing Address - Country:US
Mailing Address - Phone:623-332-0066
Mailing Address - Fax:
Practice Address - Street 1:734 W POLK ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85007-2539
Practice Address - Country:US
Practice Address - Phone:602-848-3323
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-25
Last Update Date:2024-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLAC-19691101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor