Provider Demographics
NPI:1205009289
Name:HALE, SHELLEY J
Entity Type:Individual
Prefix:
First Name:SHELLEY
Middle Name:J
Last Name:HALE
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 1:65 IRISH LN
Mailing Address - Street 2:
Mailing Address - City:MARTINSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:25403-5171
Mailing Address - Country:US
Mailing Address - Phone:304-274-5007
Mailing Address - Fax:
Practice Address - Street 1:515 W MARTIN ST
Practice Address - Street 2:
Practice Address - City:MARTINSBURG
Practice Address - State:WV
Practice Address - Zip Code:25401-2719
Practice Address - Country:US
Practice Address - Phone:304-264-5061
Practice Address - Fax:304-264-5058
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-10
Last Update Date:2008-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV2599103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0166465000Medicaid