Healthcare Provider Details

I. General information

NPI: 1164608030
Provider Name (Legal Business Name): DIANE K HAUG M.A., LPCC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/10/2008
Last Update Date: 01/10/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

39 CAMINO LA CUEVA
GLORIETA NM
87535-7012
US

IV. Provider business mailing address

39 CAMINO LA CUEVA
GLORIETA NM
87535-7012
US

V. Phone/Fax

Practice location:
  • Phone: 505-757-2939
  • Fax:
Mailing address:
  • Phone: 505-757-2939
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number1217
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: