Provider Demographics
NPI:1578141990
Name:MACK, HALEY (DPT)
Entity Type:Individual
Prefix:
First Name:HALEY
Middle Name:
Last Name:MACK
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:HALEY
Other - Middle Name:
Other - Last Name:MCDANIEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:6824 TERRY DR
Mailing Address - Street 2:
Mailing Address - City:FORT BENNING
Mailing Address - State:GA
Mailing Address - Zip Code:31905-2758
Mailing Address - Country:US
Mailing Address - Phone:214-796-6746
Mailing Address - Fax:719-495-8685
Practice Address - Street 1:6298 VETERANS PKWY STE 5A
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31909-6245
Practice Address - Country:US
Practice Address - Phone:719-488-0120
Practice Address - Fax:719-488-1427
Is Sole Proprietor?:No
Enumeration Date:2021-03-29
Last Update Date:2023-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPTL.0017520225100000X
GAPT015796225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist