Provider Demographics
NPI:1598066995
Name:TERHAAR, KEITH MICHAEL
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:MICHAEL
Last Name:TERHAAR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2005 141ST LN NE
Mailing Address - Street 2:
Mailing Address - City:HAM LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55304-6841
Mailing Address - Country:US
Mailing Address - Phone:763-245-7786
Mailing Address - Fax:
Practice Address - Street 1:6776 LAKE DR
Practice Address - Street 2:210
Practice Address - City:LINO LAKES
Practice Address - State:MN
Practice Address - Zip Code:55014-1191
Practice Address - Country:US
Practice Address - Phone:763-245-7786
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-16
Last Update Date:2010-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLPC00833101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional