Healthcare Provider Details

I. General information

NPI: 1184937997
Provider Name (Legal Business Name): KIM REGINALD HALL PSYD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2010
Last Update Date: 08/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5820 YORK RD SUITE 201
BALTIMORE MD
21212-3610
US

IV. Provider business mailing address

5820 YORK RD SUITE 201
BALTIMORE MD
21212-3610
US

V. Phone/Fax

Practice location:
  • Phone: 410-800-2169
  • Fax: 410-777-8742
Mailing address:
  • Phone: 410-800-2169
  • Fax: 410-777-8742

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number05720
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: