Provider Demographics
NPI:1114552643
Name:HALL, MEDGINE AUGUSTE (BCBA)
Entity Type:Individual
Prefix:
First Name:MEDGINE
Middle Name:AUGUSTE
Last Name:HALL
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8753 TERRACINA LAKE DR
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33625-3011
Mailing Address - Country:US
Mailing Address - Phone:941-757-7354
Mailing Address - Fax:
Practice Address - Street 1:2688 STONEWOOD PARK LOOP
Practice Address - Street 2:
Practice Address - City:LAND O LAKES
Practice Address - State:FL
Practice Address - Zip Code:34638-6210
Practice Address - Country:US
Practice Address - Phone:813-481-9662
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-04
Last Update Date:2021-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-20-114018106S00000X
FL1-21-47869103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician