Provider Demographics
NPI:1831646082
Name:HALEY, MARYMIKE (MA , LAC)
Entity Type:Individual
Prefix:
First Name:MARYMIKE
Middle Name:
Last Name:HALEY
Suffix:
Gender:F
Credentials:MA , LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:246 GARFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:CO
Mailing Address - Zip Code:81623-2133
Mailing Address - Country:US
Mailing Address - Phone:970-596-3377
Mailing Address - Fax:
Practice Address - Street 1:246 GARFIELD AVE
Practice Address - Street 2:
Practice Address - City:CARBONDALE
Practice Address - State:CO
Practice Address - Zip Code:81623-2133
Practice Address - Country:US
Practice Address - Phone:970-596-3377
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-06
Last Update Date:2016-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CONLC.0006576101YA0400X
ACB.0007777101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)