Provider Demographics
NPI:1518141266
Name:HALL, LACRESHA LABANKS (MD)
Entity Type:Individual
Prefix:
First Name:LACRESHA
Middle Name:LABANKS
Last Name:HALL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11031 NE 6TH AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33161-7182
Mailing Address - Country:US
Mailing Address - Phone:305-398-6100
Mailing Address - Fax:305-757-4465
Practice Address - Street 1:450 E ATLANTIC BLVD
Practice Address - Street 2:
Practice Address - City:POMPANO BEACH
Practice Address - State:FL
Practice Address - Zip Code:33060-6256
Practice Address - Country:US
Practice Address - Phone:954-781-4405
Practice Address - Fax:954-785-6120
Is Sole Proprietor?:No
Enumeration Date:2007-12-18
Last Update Date:2009-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME937412084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL280217100Medicaid
FLBD945ZMedicare PIN