Provider Demographics
NPI:1720016645
Name:HALEY, CONNIE (PHD, LP)
Entity Type:Individual
Prefix:DR
First Name:CONNIE
Middle Name:
Last Name:HALEY
Suffix:
Gender:F
Credentials:PHD, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5665 W MAPLE RD
Mailing Address - Street 2:STE. A
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48322-3741
Mailing Address - Country:US
Mailing Address - Phone:248-538-1958
Mailing Address - Fax:248-626-8836
Practice Address - Street 1:5665 W MAPLE RD
Practice Address - Street 2:STE. A
Practice Address - City:WEST BLOOMFIELD
Practice Address - State:MI
Practice Address - Zip Code:48322-3741
Practice Address - Country:US
Practice Address - Phone:248-538-1958
Practice Address - Fax:248-626-8836
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301006010103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI680F301210OtherBLUE CROSS BLUE SHIELD
MION87650Medicare ID - Type Unspecified