Healthcare Provider Details

I. General information

NPI: 1982301677
Provider Name (Legal Business Name): KANDACE-MA'AT HALL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KANDACE-MA'AT BOOKER

II. Dates (important events)

Enumeration Date: 02/13/2023
Last Update Date: 01/02/2025
Certification Date: 01/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2920 W BROAD ST STE 215
RICHMOND VA
23230-5103
US

IV. Provider business mailing address

1215 RENNIE AVE
RICHMOND VA
23227-4722
US

V. Phone/Fax

Practice location:
  • Phone: 804-988-1150
  • Fax:
Mailing address:
  • Phone: 804-874-2256
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number0134000479
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License Number0134000479
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: