Provider Demographics
NPI:1275781858
Name:TAN-HAASE, KELLY (PSYD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:TAN-HAASE
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1521 CONCORD PIKE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19803
Mailing Address - Country:US
Mailing Address - Phone:302-428-0205
Mailing Address - Fax:302-428-1123
Practice Address - Street 1:1521 CONCORD PIKE
Practice Address - Street 2:SUITE 103
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19803
Practice Address - Country:US
Practice Address - Phone:302-428-0205
Practice Address - Fax:302-428-1123
Is Sole Proprietor?:No
Enumeration Date:2008-09-08
Last Update Date:2009-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103T00000X
DEB1-0000787103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE015467782OtherBLUE CROSS
DE178385OtherCOMPSYCH
DE2650058OtherCIGNA
MD922801200Medicaid