Healthcare Provider Details

I. General information

NPI: 1740844844
Provider Name (Legal Business Name): SHANTIELA HALL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/24/2019
Last Update Date: 04/24/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1238 OXFORD HILL CT APT 9
SAINT LOUIS MO
63146-5721
US

IV. Provider business mailing address

1238 OXFORD HILL CT APT 9
SAINT LOUIS MO
63146-5721
US

V. Phone/Fax

Practice location:
  • Phone: 314-680-4878
  • Fax:
Mailing address:
  • Phone: 314-680-4878
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TH0100X
TaxonomyHealth Service Psychologist
License Number168641
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: