Provider Demographics
NPI:1831597392
Name:HALL, GENESIS A (LCSW)
Entity type:Individual
Prefix:
First Name:GENESIS
Middle Name:A
Last Name:HALL
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:324 REEVESTON DR
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61705-5001
Mailing Address - Country:US
Mailing Address - Phone:773-587-6062
Mailing Address - Fax:
Practice Address - Street 1:707 N EAST ST
Practice Address - Street 2:SUITE 3
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61701-3059
Practice Address - Country:US
Practice Address - Phone:773-587-6062
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-16
Last Update Date:2015-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0156581041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical