MEDICARE: HALLIE LIGHTDALE M.D.

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	2084P0800X	Psychiatry Physician	35558	DC

General Provider Information

NPI Number	:	1922083682
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	HALLIE LIGHTDALE M.D.

Provider Business Mailing Address
First Line	:	2737 DEVONSHIRE PL NW
Second Line	:	#123
City	:	WASHINGTON
State	:	DC
Zip	:	20008-3479
Country	:	US
Telephone Number	:	718-637-7679
Fax Number	:

Provider Business Practice Location Address
First Line	:	2737 DEVONSHIRE PL NW
Second Line	:	#123
City	:	WASHINGTON
State	:	DC
Zip	:	20008-3479
Country	:	US
Telephone Number	:	718-637-7679
Fax Number	:

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

Provider Enumeration Date	:	12/14/2005
Last Update Date	:	07/08/2007

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