MEDICARE: PENELOPE HALE 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	103TC0700X	Clinical Psychologist	6301002422	MI

General Provider Information

NPI Number	:	1700961158
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PENELOPE HALE PH.D

Provider Business Mailing Address
First Line	:	523 BARRINGTON RD
Second Line	:
City	:	GROSSE POINTE PARK
State	:	MI
Zip	:	48230-1721
Country	:	US
Telephone Number	:	313-278-7777
Fax Number	:

Provider Business Practice Location Address
First Line	:	19855 OUTER DR
Second Line	:	STE 103W
City	:	DEARBORN
State	:	MI
Zip	:	48124-2022
Country	:	US
Telephone Number	:	313-278-7777
Fax Number	:

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

Provider Enumeration Date	:	10/26/2006
Last Update Date	:	07/08/2007

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