Provider Demographics
NPI:1972853489
Name:HALL, CARDIA
Entity Type:Individual
Prefix:
First Name:CARDIA
Middle Name:
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 1:827 CLARKSON AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11203-2256
Mailing Address - Country:US
Mailing Address - Phone:718-735-7151
Mailing Address - Fax:718-735-7141
Practice Address - Street 1:827 CLARKSON AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11203-2256
Practice Address - Country:US
Practice Address - Phone:718-735-7151
Practice Address - Fax:718-735-7141
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-12
Last Update Date:2012-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1129044722252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1992903736Medicaid