Provider Demographics
NPI:1073865812
Name:HALL, CHALYSE A (MS)
Entity Type:Individual
Prefix:MRS
First Name:CHALYSE
Middle Name:A
Last Name:HALL
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5014 ELIZABETH AVE
Mailing Address - Street 2:
Mailing Address - City:CHUBBUCK
Mailing Address - State:ID
Mailing Address - Zip Code:83202-1606
Mailing Address - Country:US
Mailing Address - Phone:208-240-4321
Mailing Address - Fax:
Practice Address - Street 1:1110 CALL CREEK DR
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-3001
Practice Address - Country:US
Practice Address - Phone:208-233-4660
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-03
Last Update Date:2013-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDTSLP2363235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist