Provider Demographics
NPI:1659878767
Name:HALL, LORETTA YVONNE
Entity Type:Individual
Prefix:
First Name:LORETTA
Middle Name:YVONNE
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 1:310 E 115TH ST APT 8D
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10029-2248
Mailing Address - Country:US
Mailing Address - Phone:929-289-5533
Mailing Address - Fax:
Practice Address - Street 1:391 E 149TH ST RM 417
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10455-3907
Practice Address - Country:US
Practice Address - Phone:646-702-6965
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-06
Last Update Date:2018-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY171M00000X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty