Provider Demographics
NPI:1245996149
Name:BODINE-HAAG, BIANCA LEE (LADC)
Entity type:Individual
Prefix:
First Name:BIANCA
Middle Name:LEE
Last Name:BODINE-HAAG
Suffix:
Gender:F
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:585 CLEVELAND AVE S
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55116-1237
Mailing Address - Country:US
Mailing Address - Phone:612-615-3221
Mailing Address - Fax:
Practice Address - Street 1:1409 WILLOW ST STE 400
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55403-3251
Practice Address - Country:US
Practice Address - Phone:612-445-0225
Practice Address - Fax:612-445-0112
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-15
Last Update Date:2023-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNCC03877101YM0800X
MN305716101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty