MEDICARE: KEITH MICHAEL TERHAAR

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	LPC00833	MN

General Provider Information

NPI Number	:	1598066995
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KEITH MICHAEL TERHAAR

Provider Business Mailing Address
First Line	:	2005 141ST LN NE
Second Line	:
City	:	HAM LAKE
State	:	MN
Zip	:	55304-6841
Country	:	US
Telephone Number	:	763-245-7786
Fax Number	:

Provider Business Practice Location Address
First Line	:	6776 LAKE DR
Second Line	:	210
City	:	LINO LAKES
State	:	MN
Zip	:	55014-1191
Country	:	US
Telephone Number	:	763-245-7786
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/16/2010
Last Update Date	:	11/16/2010

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