Provider Demographics
NPI:1770004913
Name:HALLOCK, DONNA RAE
Entity Type:Individual
Prefix:
First Name:DONNA
Middle Name:RAE
Last Name:HALLOCK
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 1:205 8TH ST
Mailing Address - Street 2:
Mailing Address - City:HOQUIAM
Mailing Address - State:WA
Mailing Address - Zip Code:98550-2507
Mailing Address - Country:US
Mailing Address - Phone:360-532-8629
Mailing Address - Fax:360-532-8786
Practice Address - Street 1:205 8TH ST
Practice Address - Street 2:
Practice Address - City:HOQUIAM
Practice Address - State:WA
Practice Address - Zip Code:98550-2507
Practice Address - Country:US
Practice Address - Phone:360-532-8629
Practice Address - Fax:360-532-8786
Is Sole Proprietor?:No
Enumeration Date:2017-06-28
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA60768079Medicaid