Provider Demographics
NPI:1669039764
Name:HALL, MATTHEW (PHD, LP)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:
Last Name:HALL
Suffix:
Gender:M
Credentials:PHD, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2504 8TH ST
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55110-5722
Mailing Address - Country:US
Mailing Address - Phone:612-327-6613
Mailing Address - Fax:
Practice Address - Street 1:4756 BANNING AVE STE 208
Practice Address - Street 2:
Practice Address - City:WHITE BEAR LAKE
Practice Address - State:MN
Practice Address - Zip Code:55110-3206
Practice Address - Country:US
Practice Address - Phone:651-505-0851
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-23
Last Update Date:2021-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP6332103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist