Provider Demographics
NPI:1437706207
Name:BLACKER, HALEY AMANDA
Entity type:Individual
Prefix:
First Name:HALEY
Middle Name:AMANDA
Last Name:BLACKER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:HALEY
Other - Middle Name:AMANDA
Other - Last Name:BARRETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8988 PEONY LN N
Mailing Address - Street 2:
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55311-4445
Mailing Address - Country:US
Mailing Address - Phone:936-671-1045
Mailing Address - Fax:
Practice Address - Street 1:3395 PLYMOUTH RD
Practice Address - Street 2:
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55305-3633
Practice Address - Country:US
Practice Address - Phone:952-939-0396
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-26
Last Update Date:2024-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN528791235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist