Basic Information
| Provider Information | |||||||||
| NPI: | 1578544052 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HALVERSON | ||||||||
| FirstName: | MARY | ||||||||
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| Credential: | RN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 642 DAMERON DR | ||||||||
| Address2: | |||||||||
| City: | PRESCOTT | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 86301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9284455211 | ||||||||
| FaxNumber: | 9287768484 | ||||||||
| Practice Location | |||||||||
| Address1: | 505 S CORTEZ | ||||||||
| Address2: | WEST YAYAPAI GUDIANCE CLINIC INC CORTEZ CLINIC | ||||||||
| City: | PRESCOTT | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 86303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9284455211 | ||||||||
| FaxNumber: | 9287768484 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/10/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WP0808X | RN029291 | AZ | Y | Nursing Service Providers | Registered Nurse | Psych/Mental Health |
No ID Information.