Provider Demographics
NPI:1578544052
Name:HALVERSON, MARY (RN)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:HALVERSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:642 DAMERON DR
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86301
Mailing Address - Country:US
Mailing Address - Phone:928-445-5211
Mailing Address - Fax:928-776-8484
Practice Address - Street 1:505 S CORTEZ
Practice Address - Street 2:WEST YAYAPAI GUDIANCE CLINIC INC CORTEZ CLINIC
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86303
Practice Address - Country:US
Practice Address - Phone:928-445-5211
Practice Address - Fax:928-776-8484
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN029291163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health