MEDICARE: HALEY HARRELL MCGONAGILL DPT

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	225100000X	Physical Therapist	P15622	NC

General Provider Information

NPI Number	:	1891175105
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	HALEY HARRELL MCGONAGILL DPT

Provider Business Mailing Address
First Line	:	6000 RAMSEY ST STE 108
Second Line	:
City	:	FAYETTEVILLE
State	:	NC
Zip	:	28311-7189
Country	:	US
Telephone Number	:	910-484-3332
Fax Number	:	910-483-7301

Provider Business Practice Location Address
First Line	:	6000 RAMSEY ST STE 108
Second Line	:
City	:	FAYETTEVILLE
State	:	NC
Zip	:	28311-7189
Country	:	US
Telephone Number	:	910-484-3332
Fax Number	:	910-483-7301

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

Provider Enumeration Date	:	06/02/2015
Last Update Date	:	10/16/2020

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