=====================================================
General NPI Number Information
=====================================================
NPI Number | 1477752772
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | HEATHER JON HALL PHD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/16/2007
-----------------------------------------------------
Last Update Date | 06/23/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4650 W SUNSET BLVD MS#53
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90027-6062
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-361-8866
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4650 W SUNSET BLVD MS#53
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90027-6062
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-361-8866
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC2200X
-----------------------------------------------------
Taxonomy Name | Clinical Child & Adolescent Psychologist
-----------------------------------------------------
License Number | PSY25816
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------