Provider Demographics
NPI:1316011547
Name:HALLEY, GUSTAVO R (PSYD)
Entity Type:Individual
Prefix:DR
First Name:GUSTAVO
Middle Name:R
Last Name:HALLEY
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:GUSTAVO
Other - Middle Name:R
Other - Last Name:HALLEY JULIA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PSYD
Mailing Address - Street 1:2124 LONGMONT DR
Mailing Address - Street 2:
Mailing Address - City:WAKE FOREST
Mailing Address - State:NC
Mailing Address - Zip Code:27587-5910
Mailing Address - Country:US
Mailing Address - Phone:787-362-5479
Mailing Address - Fax:
Practice Address - Street 1:8601 SIX FORKS RD STE 400
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27615-5276
Practice Address - Country:US
Practice Address - Phone:919-356-1739
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-20
Last Update Date:2023-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPS1194103TC0700X
PR02002103TC0700X
NC6320103TH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR0084919Medicare UPIN
PRQ16499Medicare UPIN