Provider Demographics
NPI:1821493586
Name:HAISE, AALIYAH (MSW,LPN)
Entity Type:Individual
Prefix:
First Name:AALIYAH
Middle Name:
Last Name:HAISE
Suffix:
Gender:F
Credentials:MSW,LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 EXCALIBER CIR
Mailing Address - Street 2:104
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22406-6482
Mailing Address - Country:US
Mailing Address - Phone:540-661-9007
Mailing Address - Fax:
Practice Address - Street 1:102 EXCALIBER CIR
Practice Address - Street 2:104
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22406-6482
Practice Address - Country:US
Practice Address - Phone:540-661-9007
Practice Address - Fax:703-890-2969
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-23
Last Update Date:2014-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAS4493401251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0172986405Medicaid