Healthcare Provider Details

I. General information

NPI: 1417467283
Provider Name (Legal Business Name): JAMES A. HALEY VA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/06/2017
Last Update Date: 11/17/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13000 BRUCE B DOWNS BLVD
TAMPA FL
33612-4745
US

IV. Provider business mailing address

13000 BRUCE B DOWNS BLVD
TAMPA FL
33612-4745
US

V. Phone/Fax

Practice location:
  • Phone: 813-972-2000
  • Fax:
Mailing address:
  • Phone: 813-998-8000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number2017019227
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number2017019227
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code261QV0200X
TaxonomyVA Clinic/Center
License Number2017019227
License Number StateMO

VIII. Authorized Official

Name: DR. JOOHYUN LEE
Title or Position: PSYCHOLOGIST
Credential: PHD
Phone: 813-972-2000