Basic Information
| Provider Information | |||||||||
| NPI: | 1811176191 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HAAS | ||||||||
| FirstName: | SUZAN | ||||||||
| MiddleName: | KAY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 505 S MAIN ST | ||||||||
| Address2: | SUITE 249 | ||||||||
| City: | LAS CRUCES | ||||||||
| State: | NM | ||||||||
| PostalCode: | 880011206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5055275823 | ||||||||
| FaxNumber: | 5055275886 | ||||||||
| Practice Location | |||||||||
| Address1: | 505 S MAIN ST | ||||||||
| Address2: | SUITE 249 | ||||||||
| City: | LAS CRUCES | ||||||||
| State: | NM | ||||||||
| PostalCode: | 880011206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5055275823 | ||||||||
| FaxNumber: | 5055275886 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/02/2007 | ||||||||
| LastUpdateDate: | 11/02/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 0106771 | NM | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 87175835 | 05 | NM | MEDICAID |