1720549579 NPI number — TRACEY Y HALL BS BEHAVIORAL SERV,

Table of content: TRACEY Y HALL BS BEHAVIORAL SERV, (NPI 1720549579)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720549579 NPI number — TRACEY Y HALL BS BEHAVIORAL SERV,

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HALL
Provider First Name:
TRACEY
Provider Middle Name:
Y
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
BS BEHAVIORAL SERV,
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1720549579
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/26/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
301 E 21ST ST APT BSMT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHEYENNE
Provider Business Mailing Address State Name:
WY
Provider Business Mailing Address Postal Code:
82001-3761
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
307-275-5981
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
205 STOREY BLVD STE 120
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHEYENNE
Provider Business Practice Location Address State Name:
WY
Provider Business Practice Location Address Postal Code:
82009-3566
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
307-459-6160
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/26/2019

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 106S00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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