Basic Information
| Provider Information | |||||||||
| NPI: | 1912041237 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HALEY | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | JON | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4856 INNOVATION DR | ||||||||
| Address2: | |||||||||
| City: | FORT COLLINS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805255539 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9704944200 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1250 N WILSON AVE | ||||||||
| Address2: | |||||||||
| City: | LOVELAND | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805374461 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9704944200 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/19/2007 | ||||||||
| LastUpdateDate: | 12/18/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/18/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 1041C0700X | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.