Healthcare Provider Details

I. General information

NPI: 1396663761
Provider Name (Legal Business Name): HAILEY BOPP
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2026
Last Update Date: 07/06/2026
Certification Date: 07/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2851 S GRANITE ST
GILBERT AZ
85295-8324
US

IV. Provider business mailing address

2851 S GRANITE ST
GILBERT AZ
85295-8324
US

V. Phone/Fax

Practice location:
  • Phone: 480-316-4699
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: