Healthcare Provider Details

I. General information

NPI: 1134762099
Provider Name (Legal Business Name): HAILEY MAIRE LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/23/2019
Last Update Date: 08/23/2023
Certification Date: 08/23/2023
Deactivation Date: 08/08/2023
Reactivation Date: 08/23/2023

III. Provider practice location address

489 W 1400 N
OREM UT
84057-7000
US

IV. Provider business mailing address

489 W 1400 N
OREM UT
84057-7000
US

V. Phone/Fax

Practice location:
  • Phone: 801-438-4045
  • Fax:
Mailing address:
  • Phone: 801-438-4045
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW40586
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCSW008254
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSWIA.SC.61295735
License Number StateWA
# 4
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number120709
License Number StateIA
# 5
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number2022018693
License Number StateMO
# 6
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number120798
License Number StateIA
# 7
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLSCSW06178
License Number StateKS
# 8
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number10834432-3501
License Number StateUT

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: