Healthcare Provider Details

I. General information

NPI: 1356653992
Provider Name (Legal Business Name): PAMELA O HALL LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2010
Last Update Date: 07/12/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4740 N CLARK ST
CHICAGO IL
60640-4689
US

IV. Provider business mailing address

4734 N KENMORE AVE 2ND FLOOR
CHICAGO IL
60640-5016
US

V. Phone/Fax

Practice location:
  • Phone: 773-769-0205
  • Fax:
Mailing address:
  • Phone: 314-477-3163
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149014216
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: