Provider Demographics
NPI:1083784425
Name:HAECKER, ERNEST E (MS,CCC-A, ABA)
Entity Type:Individual
Prefix:MR
First Name:ERNEST
Middle Name:E
Last Name:HAECKER
Suffix:
Gender:M
Credentials:MS,CCC-A, ABA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 187
Mailing Address - Street 2:
Mailing Address - City:WAGON MOUND
Mailing Address - State:NM
Mailing Address - Zip Code:87752-0187
Mailing Address - Country:US
Mailing Address - Phone:505-820-7657
Mailing Address - Fax:
Practice Address - Street 1:101 N 2ND ST
Practice Address - Street 2:
Practice Address - City:RATON
Practice Address - State:NM
Practice Address - Zip Code:87740-3803
Practice Address - Country:US
Practice Address - Phone:505-445-7090
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-09
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM216231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM54858Medicaid