Healthcare Provider Details

I. General information

NPI: 1669033056
Provider Name (Legal Business Name): HALEY ALLEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2019
Last Update Date: 01/27/2023
Certification Date: 01/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

405 HUNTER ST
ESPANOLA NM
87532-2656
US

IV. Provider business mailing address

1225 BROADRICK DR
DALTON GA
30720-2504
US

V. Phone/Fax

Practice location:
  • Phone: 618-447-2422
  • Fax:
Mailing address:
  • Phone: 706-272-6199
  • Fax: 706-281-5618

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT007354
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number7029
License Number StateTN
# 3
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number4660
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: