Provider Demographics
NPI:1841474558
Name:HAEFKE, TINA
Entity type:Individual
Prefix:MRS
First Name:TINA
Middle Name:
Last Name:HAEFKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14839 254TH RD
Mailing Address - Street 2:
Mailing Address - City:HOLTON
Mailing Address - State:KS
Mailing Address - Zip Code:66436-8764
Mailing Address - Country:US
Mailing Address - Phone:785-364-5060
Mailing Address - Fax:
Practice Address - Street 1:14839 254TH RD
Practice Address - Street 2:
Practice Address - City:HOLTON
Practice Address - State:KS
Practice Address - Zip Code:66436-8764
Practice Address - Country:US
Practice Address - Phone:785-364-5060
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-18
Last Update Date:2007-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSLMSW 30951041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical