Provider Demographics
NPI:1457306433
Name:HALL, DIEDRE MICHELLE
Entity Type:Individual
Prefix:
First Name:DIEDRE
Middle Name:MICHELLE
Last Name:HALL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3229 S ALAMEDA ST
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78404-2507
Mailing Address - Country:US
Mailing Address - Phone:361-814-4800
Mailing Address - Fax:361-184-4830
Practice Address - Street 1:3229 S ALAMEDA ST
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78404-2507
Practice Address - Country:US
Practice Address - Phone:361-814-4800
Practice Address - Fax:361-814-4830
Is Sole Proprietor?:No
Enumeration Date:2006-05-24
Last Update Date:2024-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1112217225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX612068Medicare PIN