Provider Demographics
NPI:1346601804
Name:BISANZ-HAAS, COLETTE MAUREEN (MA, LADC)
Entity Type:Individual
Prefix:
First Name:COLETTE
Middle Name:MAUREEN
Last Name:BISANZ-HAAS
Suffix:
Gender:F
Credentials:MA, LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9301 BRYANT AVE S
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55420-3436
Mailing Address - Country:US
Mailing Address - Phone:952-562-3740
Mailing Address - Fax:952-405-9723
Practice Address - Street 1:9301 BRYANT AVE S STE 107
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55420-3438
Practice Address - Country:US
Practice Address - Phone:952-562-3740
Practice Address - Fax:952-405-9723
Is Sole Proprietor?:No
Enumeration Date:2016-03-11
Last Update Date:2016-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1077449-2CDT101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN472356918Medicaid