Provider Demographics
NPI:1629735634
Name:HADNOT, MARLO HALEY
Entity Type:Individual
Prefix:
First Name:MARLO
Middle Name:HALEY
Last Name:HADNOT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14469 RODEO DR APT 20
Mailing Address - Street 2:
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92395-4161
Mailing Address - Country:US
Mailing Address - Phone:909-688-4074
Mailing Address - Fax:
Practice Address - Street 1:14469 RODEO DR APT 20
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92395-4161
Practice Address - Country:US
Practice Address - Phone:909-688-4074
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-24
Last Update Date:2021-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAN4117236390200000X, 101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAN4117236OtherMEDICAL & NON MEDICAL TRANSPORTATION
CA695288OtherMEDICAL & NON MEDICAL TRANSPORTATION