MEDICARE: FULL STACK PSYCHOLOGY

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	103T00000X	Psychologist

General Provider Information

NPI Number	:	1992527642
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FULL STACK PSYCHOLOGY

Provider Business Mailing Address
First Line	:	2550 ALBANY AVENUE, #1122
Second Line	:
City	:	WEST HARTFORD
State	:	CT
Zip	:	06117-2335
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2550 ALBANY AVENUE, #1122
Second Line	:
City	:	WEST HARTFORD
State	:	CT
Zip	:	06117-2335
Country	:	US
Telephone Number	:	860-544-5734
Fax Number	:

Authorized Official
Title or Position	:	OWNER, NEUROPSYCHOLOGIST
Name	:	DR. ARIELLE HALL
Credential	:	PSY.D.
Telephone Number	:	860-544-5734

Provider Enumeration Date	:	10/24/2024
Last Update Date	:	11/25/2024

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