Provider Demographics
NPI:1548608839
Name:HALL, IVY (PHD)
Entity Type:Individual
Prefix:DR
First Name:IVY
Middle Name:
Last Name:HALL
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:IVY
Other - Middle Name:
Other - Last Name:PAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:103 BODIN CIR BLDG 778
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:94535-1801
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:103 BODIN CIR BLDG 778
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CA
Practice Address - Zip Code:94535-1801
Practice Address - Country:US
Practice Address - Phone:707-437-1814
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-07
Last Update Date:2018-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA26490103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical