Healthcare Provider Details

I. General information

NPI: 1356660377
Provider Name (Legal Business Name): DIANE M HALL LCPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2010
Last Update Date: 05/04/2021
Certification Date: 05/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6 TELCOM DR
BANGOR ME
04401-3072
US

IV. Provider business mailing address

PO BOX 1599
BANGOR ME
04402-1599
US

V. Phone/Fax

Practice location:
  • Phone: 207-947-0147
  • Fax: 207-990-3365
Mailing address:
  • Phone: 207-404-8200
  • Fax: 207-947-0435

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCC2063
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: