Provider Demographics
NPI:1336798172
Name:PARK, HAYLEY SUSANNE (MT-BC)
Entity Type:Individual
Prefix:MRS
First Name:HAYLEY
Middle Name:SUSANNE
Last Name:PARK
Suffix:
Gender:F
Credentials:MT-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 N US HIGHWAY 89 BLDG 148
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86313-5001
Mailing Address - Country:US
Mailing Address - Phone:928-445-4860
Mailing Address - Fax:
Practice Address - Street 1:500 N US HIGHWAY 89 BLDG 148
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86313-5001
Practice Address - Country:US
Practice Address - Phone:928-445-4860
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-04
Last Update Date:2020-11-18
Deactivation Date:2019-09-05
Deactivation Code:
Reactivation Date:2020-11-18
Provider Licenses
StateLicense IDTaxonomies
AZ13584225A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225A00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMusic Therapist