Healthcare Provider Details

I. General information

NPI: 1952468167
Provider Name (Legal Business Name): MARY LYNN HALL MA, LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/03/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12139 EDDIE AND PARK RD
SAINT LOUIS MO
63126-2926
US

IV. Provider business mailing address

12139 EDDIE AND PARK RD
SAINT LOUIS MO
63126-2926
US

V. Phone/Fax

Practice location:
  • Phone: 314-849-9879
  • Fax:
Mailing address:
  • Phone: 314-849-9879
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number000275
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: