Healthcare Provider Details

I. General information

NPI: 1619110921
Provider Name (Legal Business Name): HALLA-BAUER PSYCHOLOGICAL SERVICES CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/16/2009
Last Update Date: 04/16/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 MEDICAL DR SUITE 705
LAGRANGE GA
30240-4130
US

IV. Provider business mailing address

300 MEDICAL DR SUITE 705
LAGRANGE GA
30240-4130
US

V. Phone/Fax

Practice location:
  • Phone: 706-885-0111
  • Fax: 706-885-0607
Mailing address:
  • Phone: 706-885-0111
  • Fax: 706-885-0607

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY003092
License Number StateGA

VIII. Authorized Official

Name: HEIDI ANN HALLA-BAUER
Title or Position: PSYCHOLOGIST/OWNER
Credential: PSYD
Phone: 706-885-0111