Provider Demographics
NPI:1568530954
Name:HAVSTAD, MARY ANN (MA LICSW)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ANN
Last Name:HAVSTAD
Suffix:
Gender:F
Credentials:MA LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3703 TOWNDALE DR
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55431-1047
Mailing Address - Country:US
Mailing Address - Phone:612-518-5105
Mailing Address - Fax:952-881-3588
Practice Address - Street 1:9001 E BLGTN FRWY
Practice Address - Street 2:SUITE 140
Practice Address - City:BLOOMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55420
Practice Address - Country:US
Practice Address - Phone:612-518-5105
Practice Address - Fax:952-881-3588
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN8300101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health