Healthcare Provider Details

I. General information

NPI: 1407121643
Provider Name (Legal Business Name): CHARLOTTE LOUISE HALEY PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2012
Last Update Date: 03/21/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5323 HARRY HINES BLVD
DALLAS TX
75390-7201
US

IV. Provider business mailing address

PO BOX 845347
DALLAS TX
75284-5347
US

V. Phone/Fax

Practice location:
  • Phone: 214-456-5918
  • Fax: 214-456-4325
Mailing address:
  • Phone: 214-456-5918
  • Fax: 214-456-4325

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number34724
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number34724
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: