Healthcare Provider Details

I. General information

NPI: 1528338662
Provider Name (Legal Business Name): COLTON RUSSELL HAUPT BST/PSR
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/05/2012
Last Update Date: 01/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2201 N BUFFALO DR APT 1027
LAS VEGAS NV
89128-1034
US

IV. Provider business mailing address

2201 N BUFFALO DR APT 1027
LAS VEGAS NV
89128-1034
US

V. Phone/Fax

Practice location:
  • Phone: 702-738-2322
  • Fax:
Mailing address:
  • Phone: 702-738-2322
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code102L00000X
TaxonomyPsychoanalyst
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: