Healthcare Provider Details

I. General information

NPI: 1316011547
Provider Name (Legal Business Name): GUSTAVO R. HALLEY PSYD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: GUSTAVO R HALLEY JULIA PSYD

II. Dates (important events)

Enumeration Date: 11/20/2006
Last Update Date: 07/14/2023
Certification Date: 07/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8601 SIX FORKS RD STE 400
RALEIGH NC
27615-5276
US

IV. Provider business mailing address

2124 LONGMONT DR
WAKE FOREST NC
27587-5910
US

V. Phone/Fax

Practice location:
  • Phone: 919-356-1739
  • Fax:
Mailing address:
  • Phone: 787-362-5479
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPS1194
License Number StateME
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number02002
License Number StatePR
# 3
Primary TaxonomyY
Taxonomy Code103TH0100X
TaxonomyHealth Service Psychologist
License Number6320
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: