Provider Demographics
NPI:1619716834
Name:HAYLETT, STACEY
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:HAYLETT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5902 ASPEN CIR
Mailing Address - Street 2:
Mailing Address - City:JOHNSTON
Mailing Address - State:IA
Mailing Address - Zip Code:50131-2032
Mailing Address - Country:US
Mailing Address - Phone:515-664-0024
Mailing Address - Fax:
Practice Address - Street 1:1200 SW STATE ST STE 2C
Practice Address - Street 2:
Practice Address - City:ANKENY
Practice Address - State:IA
Practice Address - Zip Code:50023-2547
Practice Address - Country:US
Practice Address - Phone:515-423-0121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-20
Last Update Date:2024-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA123958101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health