Basic Information
| Provider Information | |||||||||
| NPI: | 1235326992 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HALL MENNES | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | CELESTINE | ||||||||
| NamePrefix: | |||||||||
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| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HALL-MENNES | ||||||||
| OtherFirstName: | MARCIE | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 8055 MAYFIELD RD | ||||||||
| Address2: | STE 105 | ||||||||
| City: | CHESTERLAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440262447 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4402148027 | ||||||||
| FaxNumber: | 2162018173 | ||||||||
| Practice Location | |||||||||
| Address1: | 11100 EUCLID AVE | ||||||||
| Address2: | |||||||||
| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441061716 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2162866260 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/26/2007 | ||||||||
| LastUpdateDate: | 12/05/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/05/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0804X | 35.090550 | OH | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Child & Adolescent Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 000000538617 | 01 | OH | ANTHEM | OTHER | 421799 | 01 | OH | WELLCARE MEDICAID | OTHER | 2770943 | 05 | OH | MEDICAID | 000000225208 | 01 | OH | UNISON | OTHER | 1024582290001 | 05 | PA | MEDICAID | 9731098 | 01 | OH | AETNA | OTHER |