Basic Information
| Provider Information | |||||||||
| NPI: | 1336336254 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HAACK | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | KELLY | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PH.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3333 UNIVERSITY AVENUE SE | ||||||||
| Address2: | |||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55414 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6127285399 | ||||||||
| FaxNumber: | 6127285301 | ||||||||
| Practice Location | |||||||||
| Address1: | 3333 UNIVERSITY AVE SE | ||||||||
| Address2: | |||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554143325 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6127285399 | ||||||||
| FaxNumber: | 6127285301 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/25/2007 | ||||||||
| LastUpdateDate: | 12/31/2013 | ||||||||
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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 | 103TC0700X | LP5023 | MN | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 10025287200 | 05 | NE | MEDICAID |