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:PO BOX 2516
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83206-2516
Mailing Address - Country:US
Mailing Address - Phone:208-252-5621
Mailing Address - Fax:208-648-4167
Practice Address - Street 1:4650 HAWTHORNE RD STE 3B
Practice Address - Street 2:
Practice Address - City:CHUBBUCK
Practice Address - State:ID
Practice Address - Zip Code:83202-2376
Practice Address - Country:US
Practice Address - Phone:208-252-5621
Practice Address - Fax:208-648-4167
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-14
Last Update Date:2023-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID58483363LP0808X, 2084P0802X, 2084P0804X, 2084P0805X, 2084S0010X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
No2084P0802XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction PsychiatryGroup - 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
ID1902462039Medicaid
OR500808652Medicaid