Basic Information
| Provider Information | |||||||||
| NPI: | 1215594197 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HAYES | ||||||||
| FirstName: | AMY | ||||||||
| MiddleName: | COLLEEN | ||||||||
| NamePrefix: | |||||||||
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| Credential: | MA, NCC, LPCC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | O'BRYAN | ||||||||
| OtherFirstName: | AMANDA | ||||||||
| OtherMiddleName: | C | ||||||||
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| OtherCredential: | MA, NCC, LPCC | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 4897 MILLER TRUNK HWY STE 221 | ||||||||
| Address2: | |||||||||
| City: | HERMANTOWN | ||||||||
| State: | MN | ||||||||
| PostalCode: | 558111936 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2183197171 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4897 MILLER TRUNK HWY STE 221 | ||||||||
| Address2: | |||||||||
| City: | HERMANTOWN | ||||||||
| State: | MN | ||||||||
| PostalCode: | 558111936 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2183197171 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/25/2019 | ||||||||
| LastUpdateDate: | 05/25/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 1640 | MN | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.