Provider Demographics
NPI:1376661140
Name:BRUCHEZ-HALL, CHANTAL (PHD)
Entity Type:Individual
Prefix:DR
First Name:CHANTAL
Middle Name:
Last Name:BRUCHEZ-HALL
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 SHERIDAN SQ
Mailing Address - Street 2:11 L
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10014-6828
Mailing Address - Country:US
Mailing Address - Phone:212-255-6118
Mailing Address - Fax:
Practice Address - Street 1:156 5TH AVE
Practice Address - Street 2:SUITE 1223
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10010-7002
Practice Address - Country:US
Practice Address - Phone:212-255-6118
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-27
Last Update Date:2012-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY012255-1103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYV33501Medicare ID - Type Unspecified