Provider Demographics
NPI:1972663821
Name:HALL, KATHLEEN A (LISW)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:A
Last Name:HALL
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2626 CENTRAL AVE SW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87104-1616
Mailing Address - Country:US
Mailing Address - Phone:505-321-0794
Mailing Address - Fax:505-242-6403
Practice Address - Street 1:2626 CENTRAL AVE SW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87104-1616
Practice Address - Country:US
Practice Address - Phone:505-321-0794
Practice Address - Fax:505-242-6468
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-11
Last Update Date:2017-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMI-41531041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM000Z5411Medicaid
NM201027601OtherPRESBYTERIAN PROVIDER NUM
NMNM101453Medicaid