Provider Demographics
NPI:1013364199
Name:CARLOCK, HALEY (DNP, PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:HALEY
Middle Name:
Last Name:CARLOCK
Suffix:
Gender:F
Credentials:DNP, PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3100 W LAKE ST
Mailing Address - Street 2:SUITE 210
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55416-4527
Mailing Address - Country:US
Mailing Address - Phone:612-925-6033
Mailing Address - Fax:612-925-8496
Practice Address - Street 1:1155 FORD RD
Practice Address - Street 2:SUITE B
Practice Address - City:ST LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55426-1099
Practice Address - Country:US
Practice Address - Phone:952-378-1800
Practice Address - Fax:952-378-1714
Is Sole Proprietor?:No
Enumeration Date:2016-05-19
Last Update Date:2017-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNCNP 4630363LP0808X
MNR 197063-4363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNH400360502Medicare PIN