Provider Demographics
NPI:1497824486
Name:HADDOCK, DEBORAH C (LP, LPC)
Entity Type:Individual
Prefix:MRS
First Name:DEBORAH
Middle Name:C
Last Name:HADDOCK
Suffix:
Gender:F
Credentials:LP, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4005 W 65TH ST
Mailing Address - Street 2:SUITE 214
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55435-1720
Mailing Address - Country:US
Mailing Address - Phone:612-940-0653
Mailing Address - Fax:
Practice Address - Street 1:4005 W 65TH ST
Practice Address - Street 2:SUITE 214
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-1720
Practice Address - Country:US
Practice Address - Phone:612-940-0653
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLPC00151101YP2500X
MNLP3466103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Not Answered103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN84905701132OtherPREFERRED ONE ID
MN01H70HAOtherBCBS ID
MN62-90979OtherMEDICA ID