Healthcare Provider Details

I. General information

NPI: 1568848968
Provider Name (Legal Business Name): HAILEY HEGLAND PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/07/2015
Last Update Date: 04/06/2021
Certification Date: 04/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3800 PARK NICOLLET BLVD
ST LOUIS PARK MN
55416-2527
US

IV. Provider business mailing address

8170 33RD AVE S # MS 21110Q
BLOOMINGTON MN
55425-4516
US

V. Phone/Fax

Practice location:
  • Phone: 952-993-3123
  • Fax: 952-993-3286
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number2278-226
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY.0004345
License Number StateCO
# 3
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberLP6645
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: