Healthcare Provider Details

I. General information

NPI: 1790132793
Provider Name (Legal Business Name): AMBER NICOLE HALL PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2016
Last Update Date: 10/27/2023
Certification Date: 10/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

258 CORPORATE DR STE 203
MADISON WI
53714-2407
US

IV. Provider business mailing address

630 S 36TH AVE
WAUSAU WI
54401-3930
US

V. Phone/Fax

Practice location:
  • Phone: 855-607-8242
  • Fax:
Mailing address:
  • Phone: 855-607-8242
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number3617-57
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number3617-57
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: