Healthcare Provider Details

I. General information

NPI: 1215680293
Provider Name (Legal Business Name): CONNIE LEE HALE EDUC. PSYCHOLOGIST
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/31/2022
Last Update Date: 01/31/2022
Certification Date: 01/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22360 KERENSA COURT
MI WUK VILLAGE CA
95346-9534
US

IV. Provider business mailing address

PO BOX 249
MI WUK VILLAGE CA
95346-0249
US

V. Phone/Fax

Practice location:
  • Phone: 209-743-0238
  • Fax:
Mailing address:
  • Phone: 209-743-0238
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number3288
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: