Provider Demographics
NPI:1780322081
Name:HALL, KATHLEEN GRACE
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:GRACE
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 1:6850 ALICE ST
Mailing Address - Street 2:
Mailing Address - City:BONNERS FERRY
Mailing Address - State:ID
Mailing Address - Zip Code:83805-8733
Mailing Address - Country:US
Mailing Address - Phone:406-781-3582
Mailing Address - Fax:
Practice Address - Street 1:6850 ALICE ST
Practice Address - Street 2:
Practice Address - City:BONNERS FERRY
Practice Address - State:ID
Practice Address - Zip Code:83805-8733
Practice Address - Country:US
Practice Address - Phone:406-781-3582
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-25
Last Update Date:2022-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLPC-8003101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health