Provider Demographics
NPI:1366093940
Name:ELLIS, HALEY (MED)
Entity type:Individual
Prefix:
First Name:HALEY
Middle Name:
Last Name:ELLIS
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 741
Mailing Address - Street 2:
Mailing Address - City:KALAHEO
Mailing Address - State:HI
Mailing Address - Zip Code:96741-0741
Mailing Address - Country:US
Mailing Address - Phone:502-619-0601
Mailing Address - Fax:
Practice Address - Street 1:2970 KELE ST
Practice Address - Street 2:
Practice Address - City:LIHUE
Practice Address - State:HI
Practice Address - Zip Code:96766-1823
Practice Address - Country:US
Practice Address - Phone:808-589-1829
Practice Address - Fax:808-589-2610
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-24
Last Update Date:2019-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor