Provider Demographics
NPI:1902462039
Name:HAAS, CODY (PMHNP-BC)
Entity type:Individual
Prefix:
First Name:CODY
Middle Name:
Last Name:HAAS
Suffix:
Gender:M
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1047 S WELLS ST
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-7997
Mailing Address - Country:US
Mailing Address - Phone:208-297-3428
Mailing Address - Fax:208-297-3978
Practice Address - Street 1:1047 S WELLS ST STE 106
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-7997
Practice Address - Country:US
Practice Address - Phone:208-297-3428
Practice Address - Fax:208-297-3978
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-14
Last Update Date:2024-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR202201741NP-PP363LP0808X
ID58483363LP0808X, 2084P0804X, 2084P0805X, 2084S0010X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent PsychiatryGroup - Single Specialty
No2084P0805XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyGeriatric PsychiatryGroup - Single Specialty
No2084S0010XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologySports MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500808652Medicaid
ID1902462039Medicaid