Provider Demographics
NPI:1407989791
Name:HALL, LAURIE (PHD)
Entity Type:Individual
Prefix:
First Name:LAURIE
Middle Name:
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 1:3301 N BALLARD RD STE C
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54911-9002
Mailing Address - Country:US
Mailing Address - Phone:920-202-3954
Mailing Address - Fax:920-202-3964
Practice Address - Street 1:3301 N BALLARD RD STE C
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54911-9002
Practice Address - Country:US
Practice Address - Phone:920-202-3954
Practice Address - Fax:920-202-3964
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-14
Last Update Date:2010-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2719-057103TC0700X
IA613103TC0700X
NY15823103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1407989791Medicaid
1407989791Medicare PIN