Provider Demographics
NPI:1003460072
Name:HALLAM, JOANNA (PT, DPT)
Entity Type:Individual
Prefix:
First Name:JOANNA
Middle Name:
Last Name:HALLAM
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 12TH ST APT O
Mailing Address - Street 2:
Mailing Address - City:LA GRANDE
Mailing Address - State:OR
Mailing Address - Zip Code:97850-2864
Mailing Address - Country:US
Mailing Address - Phone:916-390-0357
Mailing Address - Fax:
Practice Address - Street 1:2519 COVE AVE
Practice Address - Street 2:
Practice Address - City:LA GRANDE
Practice Address - State:OR
Practice Address - Zip Code:97850-3910
Practice Address - Country:US
Practice Address - Phone:541-962-0830
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-29
Last Update Date:2019-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR63331225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist