Provider Demographics
NPI:1932272820
Name:HALFACRE BUIE, MARY CONSUELO (PT)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:CONSUELO
Last Name:HALFACRE BUIE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:CONSUELO
Other - Last Name:HALFACRE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PT
Mailing Address - Street 1:2200 HAVASUPA BLVD
Mailing Address - Street 2:
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86403-6798
Mailing Address - Country:US
Mailing Address - Phone:928-505-6911
Mailing Address - Fax:928-505-6991
Practice Address - Street 1:2200 HAVASUPA BLVD
Practice Address - Street 2:
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403-6798
Practice Address - Country:US
Practice Address - Phone:928-505-6911
Practice Address - Fax:928-505-6991
Is Sole Proprietor?:No
Enumeration Date:2006-11-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3864225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ728939OtherAHCCS