Provider Demographics
NPI:1851410260
Name:POUPORE HAATS, SCOTT C (LICSW)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:C
Last Name:POUPORE HAATS
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:915 E. 1ST ST.
Mailing Address - Street 2:CBO-DENFIELD, ATTN: CREDENTIALING
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55805-2107
Mailing Address - Country:US
Mailing Address - Phone:218-249-6839
Mailing Address - Fax:218-249-6880
Practice Address - Street 1:220 N 6TH AVE E
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55805-1952
Practice Address - Country:US
Practice Address - Phone:218-249-7000
Practice Address - Fax:218-249-7050
Is Sole Proprietor?:No
Enumeration Date:2007-03-28
Last Update Date:2019-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN35931041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN752813200Medicaid