Provider Demographics
NPI:1073015475
Name:ERESUMA, HAILEY
Entity Type:Individual
Prefix:
First Name:HAILEY
Middle Name:
Last Name:ERESUMA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:366 FORREST ST APT 3
Mailing Address - Street 2:
Mailing Address - City:JERSEY CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07304-2287
Mailing Address - Country:US
Mailing Address - Phone:801-657-2861
Mailing Address - Fax:
Practice Address - Street 1:366 FORREST ST APT 3
Practice Address - Street 2:
Practice Address - City:JERSEY CITY
Practice Address - State:NJ
Practice Address - Zip Code:07304-2287
Practice Address - Country:US
Practice Address - Phone:801-657-2861
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-02
Last Update Date:2018-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty