Healthcare Provider Details

I. General information

NPI: 1710250832
Provider Name (Legal Business Name): JOAN D. HAUSE L.P.C.C.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/21/2012
Last Update Date: 01/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2388 UNIVERSITY AVE W STE 202
SAINT PAUL MN
55114-1769
US

IV. Provider business mailing address

2388 UNIVERSITY AVE W STE 202
SAINT PAUL MN
55114-1769
US

V. Phone/Fax

Practice location:
  • Phone: 612-293-5124
  • Fax: 651-300-2702
Mailing address:
  • Phone: 612-293-5124
  • Fax: 651-300-2702

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number01153
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC #01153
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: