Provider Demographics
NPI:1114091709
Name:HALL, KATHRYN NAOMI (LP)
Entity Type:Individual
Prefix:MS
First Name:KATHRYN
Middle Name:NAOMI
Last Name:HALL
Suffix:
Gender:F
Credentials:LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2115 COUNTY ROAD D E
Mailing Address - Street 2:SUITE B
Mailing Address - City:MAPLEWOOD
Mailing Address - State:MN
Mailing Address - Zip Code:55109-5353
Mailing Address - Country:US
Mailing Address - Phone:651-748-5019
Mailing Address - Fax:651-773-7591
Practice Address - Street 1:2115 COUNTY ROAD D E
Practice Address - Street 2:SUITE B
Practice Address - City:MAPLEWOOD
Practice Address - State:MN
Practice Address - Zip Code:55109-5353
Practice Address - Country:US
Practice Address - Phone:651-748-5019
Practice Address - Fax:651-773-7591
Is Sole Proprietor?:No
Enumeration Date:2006-11-17
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP3782103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN036316200Medicaid
MN375G3HAOtherBLUE CROSS BLUE SHIELD
MNHP45668OtherHEALTH PARTNERS
MN6267153OtherUBH AND MEDICA
MN111201OtherBHP AND UCARE