Provider Demographics
NPI:1790873537
Name:HALLAM, LORI A (LMFT)
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:A
Last Name:HALLAM
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3707 E SOUTHERN AVE STE 1055
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85206-6205
Mailing Address - Country:US
Mailing Address - Phone:480-859-0322
Mailing Address - Fax:
Practice Address - Street 1:3707 E SOUTHERN AVE STE 1055
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85206-6205
Practice Address - Country:US
Practice Address - Phone:480-859-0322
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2021-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ0015202106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI29795-8OtherBLUE CROSS
RI412780OtherBLUE CHIP
RILH62114Medicaid