MEDICARE: MR. CALVIN HALL JR.

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy	License Number State
1	103TA0700X	Adult Development & Aging Psychologist	FL
2	103TM1800X	Intellectual & Developmental Disabilities Psychologist
3	172V00000X	Community Health Worker	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1104268952
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. CALVIN HALL JR.

Provider Business Mailing Address
First Line	:	3101 RACKLEY DR
Second Line	:
City	:	TALLAHASSEE
State	:	FL
Zip	:	32305-6737
Country	:	US
Telephone Number	:	850-524-1556
Fax Number	:

Provider Business Practice Location Address
First Line	:	3101 RACKLEY DR
Second Line	:
City	:	TALLAHASSEE
State	:	FL
Zip	:	32305-6737
Country	:	US
Telephone Number	:	850-524-1556
Fax Number	:

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

Provider Enumeration Date	:	07/22/2013
Last Update Date	:	07/22/2013

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