Provider Demographics
NPI:1386932689
Name:HAAKE, KAREN JEAN
Entity type:Individual
Prefix:
First Name:KAREN
Middle Name:JEAN
Last Name:HAAKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12301 WILLINGDON RD
Mailing Address - Street 2:
Mailing Address - City:HUNTERSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28078-5649
Mailing Address - Country:US
Mailing Address - Phone:704-948-8450
Mailing Address - Fax:
Practice Address - Street 1:12301 WILLINGDON RD
Practice Address - Street 2:
Practice Address - City:HUNTERSVILLE
Practice Address - State:NC
Practice Address - Zip Code:28078-5649
Practice Address - Country:US
Practice Address - Phone:704-948-8450
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-20
Last Update Date:2011-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC8646101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCAPPLYINGMedicaid