=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841899291
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHARLOTTE MAE GERTH HAANEN PHD, LP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/17/2020
-----------------------------------------------------
Last Update Date | 10/17/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2805 CLIFF RD E
-----------------------------------------------------
City | BURNSVILLE
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55337-4095
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 612-203-9156
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1671 CANYON LN
-----------------------------------------------------
City | NEW BRIGHTON
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55112-7240
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 612-203-9156
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | LP4832
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------