Provider Demographics
NPI:1780693515
Name:HASTY, KIM (MS, LCPC)
Entity type:Individual
Prefix:
First Name:KIM
Middle Name:
Last Name:HASTY
Suffix:
Gender:F
Credentials:MS, LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 PROFESSIONAL PARK DR # A
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62062-5669
Mailing Address - Country:US
Mailing Address - Phone:618-288-8787
Mailing Address - Fax:618-288-0737
Practice Address - Street 1:20 PROFESSIONAL PARK DR # A
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:IL
Practice Address - Zip Code:62062-5669
Practice Address - Country:US
Practice Address - Phone:618-288-8787
Practice Address - Fax:618-288-0737
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional