Provider Demographics
NPI:1174061287
Name:HAUGEN, SUSAN M (MA)
Entity type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:M
Last Name:HAUGEN
Suffix:
Gender:F
Credentials:MA
Other - Prefix:MS
Other - First Name:SUSAN
Other - Middle Name:M
Other - Last Name:HAUGEN-BASSETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA
Mailing Address - Street 1:96 MAESTAS RD UNIT A
Mailing Address - Street 2:
Mailing Address - City:RANCHOS DE TAOS
Mailing Address - State:NM
Mailing Address - Zip Code:87557-9780
Mailing Address - Country:US
Mailing Address - Phone:575-779-7804
Mailing Address - Fax:
Practice Address - Street 1:2573 STATE HIGHWAY 522
Practice Address - Street 2:
Practice Address - City:QUESTA
Practice Address - State:NM
Practice Address - Zip Code:87556
Practice Address - Country:US
Practice Address - Phone:575-586-0315
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-09
Last Update Date:2017-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0121831101YA0400X
NM0097881101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)