MEDICARE: MS. SUBRENIA A HALL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101Y00000X	Counselor	BH003188	PA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	BH003188	OTHER	PA	STATE BOARD OF MEDICINE

General Provider Information

NPI Number	:	1053964874
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. SUBRENIA A HALL

Provider Business Mailing Address
First Line	:	2637 N SARTAIN ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19133-1411
Country	:	US
Telephone Number	:	267-242-1928
Fax Number	:

Provider Business Practice Location Address
First Line	:	2637 N SARTAIN ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19133-1411
Country	:	US
Telephone Number	:	267-242-1928
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/21/2019
Last Update Date	:	07/21/2019

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