Healthcare Provider Details

I. General information

NPI: 1962684365
Provider Name (Legal Business Name): TEANNA HALL OT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/28/2007
Last Update Date: 09/06/2021
Certification Date: 09/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5130 N US HIGHWAY 89
FLAGSTAFF AZ
86004-2837
US

IV. Provider business mailing address

125 E ELM AVE STE. 103
FLAGSTAFF AZ
86001-3258
US

V. Phone/Fax

Practice location:
  • Phone: 928-773-2054
  • Fax: 928-773-2286
Mailing address:
  • Phone: 928-779-1679
  • Fax: 928-779-2822

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number3542
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number3542
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: