Provider Demographics
NPI:1922279264
Name:HAIST, PATRICIA ANNE (MA)
Entity Type:Individual
Prefix:MS
First Name:PATRICIA
Middle Name:ANNE
Last Name:HAIST
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 SHELDON BLVD SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-4209
Mailing Address - Country:US
Mailing Address - Phone:616-459-7062
Mailing Address - Fax:616-459-0392
Practice Address - Street 1:25 SHELDON BLVD SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-4209
Practice Address - Country:US
Practice Address - Phone:616-459-7062
Practice Address - Fax:616-459-0392
Is Sole Proprietor?:No
Enumeration Date:2008-03-14
Last Update Date:2008-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301006609103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical