Basic Information
| Provider Information | |||||||||
| NPI: | 1487081014 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HALL | ||||||||
| FirstName: | ERIN | ||||||||
| MiddleName: | JEAN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | FLEMING | ||||||||
| OtherFirstName: | ERIN | ||||||||
| OtherMiddleName: | JEAN | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 138 N COURT ST | ||||||||
| Address2: | |||||||||
| City: | WAMPSVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 131637714 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3153662327 | ||||||||
| FaxNumber: | 3153662599 | ||||||||
| Practice Location | |||||||||
| Address1: | 138 N COURT ST | ||||||||
| Address2: | |||||||||
| City: | WAMPSVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 131637714 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3153662327 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/27/2013 | ||||||||
| LastUpdateDate: | 09/16/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/16/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 093642 | NY | N | Behavioral Health & Social Service Providers | Social Worker | 1041C0700X | 092037 | NY | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 1336163963 | 05 | NY | MEDICAID |