MEDICARE: DR. MARY K HALES PH.D

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103G00000X	Clinical Neuropsychologist		UT

General Provider Information

NPI Number	:	1538137179
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARY K HALES PH.D

Provider Business Mailing Address
First Line	:	PO BOX 581017
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84158-1017
Country	:	US
Telephone Number	:	801-359-6069
Fax Number	:	801-359-6049

Provider Business Practice Location Address
First Line	:	1060 E 100 S
Second Line	:	SUITE L1
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84102-1501
Country	:	US
Telephone Number	:	801-359-6069
Fax Number	:	801-359-6049

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/09/2006
Last Update Date	:	10/29/2007

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