Healthcare Provider Details

I. General information

NPI: 1336336254
Provider Name (Legal Business Name): MARY KELLY HAACK PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/25/2007
Last Update Date: 12/31/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3333 UNIVERSITY AVE SE
MINNEAPOLIS MN
55414-3325
US

IV. Provider business mailing address

3333 UNIVERSITY AVENUE SE
MINNEAPOLIS MN
55414
US

V. Phone/Fax

Practice location:
  • Phone: 612-728-5399
  • Fax: 612-728-5301
Mailing address:
  • Phone: 612-728-5399
  • Fax: 612-728-5301

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberLP5023
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: