Provider Demographics
NPI:1376764324
Name:HALL, LYNN MARIE HALLBERG (PHD)
Entity Type:Individual
Prefix:DR
First Name:LYNN
Middle Name:MARIE HALLBERG
Last Name: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 1:17362 SANDGATE PLACE
Mailing Address - Street 2:
Mailing Address - City:WEST OLIVE
Mailing Address - State:MI
Mailing Address - Zip Code:49460
Mailing Address - Country:US
Mailing Address - Phone:616-846-0049
Mailing Address - Fax:
Practice Address - Street 1:1940 EASTERN, SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49007
Practice Address - Country:US
Practice Address - Phone:616-243-0385
Practice Address - Fax:616-243-5390
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301008500103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical