Healthcare Provider Details

I. General information

NPI: 1013364199
Provider Name (Legal Business Name): HALEY CARLOCK DNP, PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2016
Last Update Date: 04/26/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1155 FORD RD SUITE B
ST LOUIS PARK MN
55426-1099
US

IV. Provider business mailing address

3100 W LAKE ST SUITE 210
MINNEAPOLIS MN
55416-4527
US

V. Phone/Fax

Practice location:
  • Phone: 952-378-1800
  • Fax: 952-378-1714
Mailing address:
  • Phone: 612-925-6033
  • Fax: 612-925-8496

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberCNP 4630
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberR 197063-4
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: