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General NPI Number Information
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NPI Number | 1013364199
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Entity Type | Individual
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Provider Name | HALEY CARLOCK DNP, PMHNP-BC
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Gender | Female
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Dates
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Enumeration Date | 05/19/2016
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Last Update Date | 04/26/2017
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Provider Practice Location Address
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Address Line | 1155 FORD RD SUITE B
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City | ST LOUIS PARK
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State | MN
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Zip | 55426-1099
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Country | US
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Telephone | 952-378-1800
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Fax | 952-378-1714
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Provider Business Mailing Address
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Address Line | 3100 W LAKE ST SUITE 210
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City | MINNEAPOLIS
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State | MN
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Zip | 55416-4527
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Country | US
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Telephone | 612-925-6033
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Fax | 612-925-8496
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number | CNP 4630
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License Number State | MN
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Taxonomy #2
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number | R 197063-4
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License Number State | MN
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