Provider Demographics
NPI:1477190197
Name:MAIN, HALEY NICOLE
Entity Type:Individual
Prefix:
First Name:HALEY
Middle Name:NICOLE
Last Name:MAIN
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 1:120 N LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:EAGLE GROVE
Mailing Address - State:IA
Mailing Address - Zip Code:50533-1728
Mailing Address - Country:US
Mailing Address - Phone:319-981-2172
Mailing Address - Fax:
Practice Address - Street 1:800 13TH ST S
Practice Address - Street 2:
Practice Address - City:HUMBOLDT
Practice Address - State:IA
Practice Address - Zip Code:50548-2439
Practice Address - Country:US
Practice Address - Phone:515-332-4104
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-01
Last Update Date:2019-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA096560235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist