Provider Demographics
NPI:1285231266
Name:HALL, BETHANY A (TLLP)
Entity Type:Individual
Prefix:MRS
First Name:BETHANY
Middle Name:A
Last Name:HALL
Suffix:
Gender:F
Credentials:TLLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:730 S DAYTON ST
Mailing Address - Street 2:
Mailing Address - City:DAVISON
Mailing Address - State:MI
Mailing Address - Zip Code:48423-1716
Mailing Address - Country:US
Mailing Address - Phone:810-333-3860
Mailing Address - Fax:
Practice Address - Street 1:6060 DIXIE HWY STE H
Practice Address - Street 2:
Practice Address - City:CLARKSTON
Practice Address - State:MI
Practice Address - Zip Code:48346-3476
Practice Address - Country:US
Practice Address - Phone:248-270-5395
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-03
Last Update Date:2020-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6362009122103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist