Provider Demographics
NPI:1154800514
Name:HAACK, AMY (LCSW)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:HAACK
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4425 W OLIVE AVE STE 151A
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85302-3843
Mailing Address - Country:US
Mailing Address - Phone:602-456-4817
Mailing Address - Fax:
Practice Address - Street 1:4425 W OLIVE AVE STE 151A
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85302-3843
Practice Address - Country:US
Practice Address - Phone:602-456-4817
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-07
Last Update Date:2018-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ154451041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical