Provider Demographics
NPI:1548699895
Name:CORKER, HAYWARD II
Entity type:Individual
Prefix:
First Name:HAYWARD
Middle Name:
Last Name:CORKER
Suffix:II
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 GOLDEN VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55411-3139
Mailing Address - Country:US
Mailing Address - Phone:612-302-4109
Mailing Address - Fax:612-520-0047
Practice Address - Street 1:1500 GOLDEN VALLEY RD
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55411-3139
Practice Address - Country:US
Practice Address - Phone:612-302-4109
Practice Address - Fax:612-520-0047
Is Sole Proprietor?:No
Enumeration Date:2013-11-07
Last Update Date:2013-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN301563101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)