Provider Demographics
NPI:1578030870
Name:KACKLEY, HAILEY LAEL
Entity type:Individual
Prefix:
First Name:HAILEY
Middle Name:LAEL
Last Name:KACKLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2837 KINGS RETREAT CIR
Mailing Address - Street 2:
Mailing Address - City:HUMBLE
Mailing Address - State:TX
Mailing Address - Zip Code:77345-5603
Mailing Address - Country:US
Mailing Address - Phone:713-212-9724
Mailing Address - Fax:
Practice Address - Street 1:2825 W TOWN CENTER CIR
Practice Address - Street 2:
Practice Address - City:KINGWOOD
Practice Address - State:TX
Practice Address - Zip Code:77339-3734
Practice Address - Country:US
Practice Address - Phone:866-437-2165
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-25
Last Update Date:2018-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX18-62677106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician