Provider Demographics
NPI:1528065000
Name:HAUGEN, MARK L (PHD, LP)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:L
Last Name:HAUGEN
Suffix:
Gender:M
Credentials:PHD, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1526 30TH ST NW
Mailing Address - Street 2:
Mailing Address - City:BEMIDJI
Mailing Address - State:MN
Mailing Address - Zip Code:56601-4133
Mailing Address - Country:US
Mailing Address - Phone:218-751-0887
Mailing Address - Fax:
Practice Address - Street 1:1526 30TH ST NW
Practice Address - Street 2:
Practice Address - City:BEMIDJI
Practice Address - State:MN
Practice Address - Zip Code:56601-4133
Practice Address - Country:US
Practice Address - Phone:218-751-0887
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-30
Last Update Date:2019-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP1398103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN143550700Medicaid
MN143550700Medicaid
MNR04993Medicare UPIN