Basic Information
| Provider Information | |||||||||
| NPI: | 1518521681 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WALDROP | ||||||||
| FirstName: | HAYLEY | ||||||||
| MiddleName: | JO | ||||||||
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| Credential: | LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1336 | ||||||||
| Address2: | ATTN: SHARLA STARITA | ||||||||
| City: | PORTLAND | ||||||||
| State: | TX | ||||||||
| PostalCode: | 783741185 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3617773991 | ||||||||
| FaxNumber: | 3617770610 | ||||||||
| Practice Location | |||||||||
| Address1: | 101 W POTTS ST | ||||||||
| Address2: | |||||||||
| City: | FALFURRIAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 783554906 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3617773991 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/24/2019 | ||||||||
| LastUpdateDate: | 04/24/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 77016 | TX | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 77016 | 01 | TX | TEXAS STATE BOARD OF EXAMINERS OF PROFESSIONAL COUNSELORS | OTHER |