Healthcare Provider Details

I. General information

NPI: 1437148244
Provider Name (Legal Business Name): JOY M LARSEN HAIDLE M.S., C.G.C.
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 10/14/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3435 W BROADWAY AVE SUITE 1135
ROBBINSDALE MN
55422-2922
US

IV. Provider business mailing address

3435 W BROADWAY AVE SUITE 1135
ROBBINSDALE MN
55422-2922
US

V. Phone/Fax

Practice location:
  • Phone: 763-530-3815
  • Fax: 763-520-1976
Mailing address:
  • Phone: 763-530-3815
  • Fax: 763-520-1976

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code170300000X
TaxonomyGenetic Counselor (M.S.)
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: