Healthcare Provider Details

I. General information

NPI: 1326617135
Provider Name (Legal Business Name): HAILEY JO MORK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2021
Last Update Date: 06/24/2021
Certification Date: 06/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17645 JUNIPER PATH STE 205
LAKEVILLE MN
55044-7491
US

IV. Provider business mailing address

1337 ALAMEDA ST
SAINT PAUL MN
55117-4115
US

V. Phone/Fax

Practice location:
  • Phone: 507-581-2957
  • Fax:
Mailing address:
  • Phone: 320-226-3157
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225A00000X
TaxonomyMusic Therapist
License Number541990
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: