Basic Information
| Provider Information | |||||||||
| NPI: | 1023543584 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HALEY | ||||||||
| FirstName: | REBECCA | ||||||||
| MiddleName: | JOANN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 825 E 5TH ST | ||||||||
| Address2: | |||||||||
| City: | PORT ANGELES | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983623818 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604774790 | ||||||||
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| Practice Location | |||||||||
| Address1: | 825 E 5TH ST | ||||||||
| Address2: | |||||||||
| City: | PORT ANGELES | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983623818 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604774790 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/21/2017 | ||||||||
| LastUpdateDate: | 10/17/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/13/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | CP60695037 | WA | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 1023543584 | 05 | WA | MEDICAID |