MEDICARE: MRS. SABINE A HAAKE M.A.R.D.

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	103K00000X	Behavior Analyst
2	133V00000X	Registered Dietitian	805457	CA

General Provider Information

NPI Number	:	1700194545
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. SABINE A HAAKE M.A.R.D.

Provider Business Mailing Address
First Line	:	331 TAMALPAIS DR
Second Line	:
City	:	CORTE MADERA
State	:	CA
Zip	:	94925-1417
Country	:	US
Telephone Number	:	415-924-4457
Fax Number	:	415-927-4250

Provider Business Practice Location Address
First Line	:	150 NELLEN AVE
Second Line	:	SUITE 110
City	:	CORTE MADERA
State	:	CA
Zip	:	94925-1104
Country	:	US
Telephone Number	:	415-924-4457
Fax Number	:	415-927-4250

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

Provider Enumeration Date	:	09/15/2010
Last Update Date	:	09/15/2010

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