Healthcare Provider Details

I. General information

NPI: 1275506156
Provider Name (Legal Business Name): CAROLYN GRACE HALLIDAY M.A.; L.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/09/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3009 HOLMES AVE
MINNEAPOLIS MN
55408-2628
US

IV. Provider business mailing address

3009 HOLMES AVE
MINNEAPOLIS MN
55408-2628
US

V. Phone/Fax

Practice location:
  • Phone: 612-827-0332
  • Fax: 612-827-8916
Mailing address:
  • Phone: 612-827-0332
  • Fax: 612-827-8916

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License NumberLP0151
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: