Healthcare Provider Details

I. General information

NPI: 1992007603
Provider Name (Legal Business Name): KATHRYN JANE HALL LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/01/2010
Last Update Date: 09/01/2021
Certification Date: 09/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

860 S ROBERTS ST # 200
WASILLA AK
99654-0014
US

IV. Provider business mailing address

PO BOX 2653
SOLDOTNA AK
99669-2653
US

V. Phone/Fax

Practice location:
  • Phone: 79-313-7965
  • Fax: 907-531-3886
Mailing address:
  • Phone: 907-531-6047
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number114389
License Number StateAK

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: