Healthcare Provider Details

I. General information

NPI: 1376764324
Provider Name (Legal Business Name): LYNN MARIE HALLBERG HALL PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1940 EASTERN, SE
GRAND RAPIDS MI
49007
US

IV. Provider business mailing address

17362 SANDGATE PLACE
WEST OLIVE MI
49460
US

V. Phone/Fax

Practice location:
  • Phone: 616-243-0385
  • Fax: 616-243-5390
Mailing address:
  • Phone: 616-846-0049
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number6301008500
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: