Provider Demographics
NPI:1871719203
Name:HALL, LEEANN MARIE
Entity type:Individual
Prefix:MRS
First Name:LEEANN
Middle Name:MARIE
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 1:4016 3RD ST S # 1135
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32250-5848
Mailing Address - Country:US
Mailing Address - Phone:904-299-9657
Mailing Address - Fax:
Practice Address - Street 1:4016 3RD ST S # 1135
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE BEACH
Practice Address - State:FL
Practice Address - Zip Code:32250-5848
Practice Address - Country:US
Practice Address - Phone:904-299-9657
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-17
Last Update Date:2023-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMT4304106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist