MEDICARE: MRS. ANDREA MARIE HALL PHD

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	103TH0004X	Health Psychologist
2	171M00000X	Case Manager/Care Coordinator

General Provider Information

NPI Number	:	1518190107
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. ANDREA MARIE HALL PHD

Provider Business Mailing Address
First Line	:	1655 THE GREENS WAY APT 2421
Second Line	:
City	:	JACKSONVILLE BEACH
State	:	FL
Zip	:	32250-2463
Country	:	US
Telephone Number	:	904-402-7441
Fax Number	:

Provider Business Practice Location Address
First Line	:	1655 THE GREENS WAY APT 2421
Second Line	:
City	:	JACKSONVILLE BEACH
State	:	FL
Zip	:	32250-2463
Country	:	US
Telephone Number	:	904-402-7441
Fax Number	:

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

Provider Enumeration Date	:	08/28/2009
Last Update Date	:	08/28/2009

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