Healthcare Provider Details

I. General information

NPI: 1225197684
Provider Name (Legal Business Name): MARCELLE IDETTE BLAIR HALL LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARCELLE IDETTE BANKS-BLAIR LSW

II. Dates (important events)

Enumeration Date: 12/08/2006
Last Update Date: 10/11/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 N MONROE ST
MEDIA PA
19063-3052
US

IV. Provider business mailing address

2150 SPRINGHOUSE HOLW
GARNET VALLEY PA
19060-2116
US

V. Phone/Fax

Practice location:
  • Phone: 610-800-2475
  • Fax:
Mailing address:
  • Phone: 610-800-2475
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberSW125167
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCW016320
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberQ1-0001254
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: