MEDICARE: AMANDA 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	101YM0800X	Mental Health Counselor
2	101YP2500X	Professional Counselor	LPC6768	OK

General Provider Information

NPI Number	:	1659742997
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AMANDA HALL

Provider Business Mailing Address
First Line	:	4416 W HOUSTON ST
Second Line	:
City	:	BROKEN ARROW
State	:	OK
Zip	:	74012-4645
Country	:	US
Telephone Number	:	918-288-0027
Fax Number	:

Provider Business Practice Location Address
First Line	:	4416 W HOUSTON ST
Second Line	:
City	:	BROKEN ARROW
State	:	OK
Zip	:	74012-4645
Country	:	US
Telephone Number	:	918-288-0027
Fax Number	:

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

Provider Enumeration Date	:	10/13/2015
Last Update Date	:	08/02/2024

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Directions to “ AMANDA HALL ” Practice Location

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