Provider Demographics
NPI:1316008220
Name:HALL, LEOLA E (MSPT)
Entity Type:Individual
Prefix:
First Name:LEOLA
Middle Name:E
Last Name:HALL
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2170 W IRONWOOD CENTER DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-2606
Mailing Address - Country:US
Mailing Address - Phone:208-667-1988
Mailing Address - Fax:208-765-5654
Practice Address - Street 1:2170 W IRONWOOD CENTER DR
Practice Address - Street 2:SUITE B
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-2606
Practice Address - Country:US
Practice Address - Phone:208-667-1988
Practice Address - Fax:208-765-5654
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2011-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT716225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID804190200Medicaid
ID16531101Medicare PIN