Provider Demographics
NPI:1073174389
Name:HALE SURACE, ROSEMARY (PSYD)
Entity type:Individual
Prefix:
First Name:ROSEMARY
Middle Name:
Last Name:HALE SURACE
Suffix:
Gender:
Credentials:PSYD
Other - Prefix:
Other - First Name:ROSEMARY
Other - Middle Name:
Other - Last Name:HALE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 843022
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64184-3022
Mailing Address - Country:US
Mailing Address - Phone:317-770-6900
Mailing Address - Fax:317-770-6911
Practice Address - Street 1:611 E 10TH ST
Practice Address - Street 2:
Practice Address - City:SHERIDAN
Practice Address - State:IN
Practice Address - Zip Code:46069-9106
Practice Address - Country:US
Practice Address - Phone:317-758-4477
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-26
Last Update Date:2025-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20043509A103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300054533Medicaid