Provider Demographics
NPI:1629005186
Name:HALEY, SUSAN C (MD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:C
Last Name:HALEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1446 REYNOLDS RD STE 215
Mailing Address - Street 2:
Mailing Address - City:MAUMEE
Mailing Address - State:OH
Mailing Address - Zip Code:43537-1634
Mailing Address - Country:US
Mailing Address - Phone:419-794-0553
Mailing Address - Fax:419-794-0554
Practice Address - Street 1:1446 REYNOLDS RD STE 215
Practice Address - Street 2:
Practice Address - City:MAUMEE
Practice Address - State:OH
Practice Address - Zip Code:43537-1634
Practice Address - Country:US
Practice Address - Phone:419-794-0553
Practice Address - Fax:419-794-0554
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-28
Last Update Date:2020-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH350520582084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0672160Medicaid
OH000000359176OtherANTHEM
OH000000359176OtherANTHEM
OHHA0587886Medicare PIN
A16586Medicare UPIN