Provider Demographics
NPI:1477123511
Name:O'HALLORAN, MARY SEAN (LP)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:SEAN
Last Name:O'HALLORAN
Suffix:
Gender:F
Credentials:LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:525 BOWEN ST
Mailing Address - Street 2:
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80501-5333
Mailing Address - Country:US
Mailing Address - Phone:720-635-0755
Mailing Address - Fax:
Practice Address - Street 1:1751 HOVER ST
Practice Address - Street 2:STE B4
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80501-7181
Practice Address - Country:US
Practice Address - Phone:720-635-0755
Practice Address - Fax:303-223-3306
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-30
Last Update Date:2021-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2218103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist