=====================================================
General NPI Number Information
=====================================================
NPI Number | 1518364652
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KATHLEEN HALD LAC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/03/2014
-----------------------------------------------------
Last Update Date | 12/03/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 204 N MOUNT VERNON AVE 112 EAST MERRIT STREET
-----------------------------------------------------
City | PRESCOTT
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 86301-3108
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-910-0198
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 204 N MOUNT VERNON AVE
-----------------------------------------------------
City | PRESCOTT
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 86301-3108
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-910-0198
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | LAC-14477
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------