Provider Demographics
NPI:1831106723
Name:HALEY, BRENTL GERARD (PT)
Entity Type:Individual
Prefix:
First Name:BRENTL
Middle Name:GERARD
Last Name:HALEY
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 180535
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76096
Mailing Address - Country:US
Mailing Address - Phone:817-784-6323
Mailing Address - Fax:817-754-6323
Practice Address - Street 1:1201 W CAMP WISDOM RD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75232
Practice Address - Country:US
Practice Address - Phone:817-784-6323
Practice Address - Fax:817-784-6323
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1014710225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
8T4845Medicare UPIN
0031MJMedicare ID - Type Unspecified