Basic Information
| Provider Information | |||||||||
| NPI: | 1124463930 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MINTZ | ||||||||
| FirstName: | HALLIE | ||||||||
| MiddleName: | ELISE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 856 N 25TH ST | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191301834 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9089170472 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 856 N 25TH ST | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191301834 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9089170472 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/07/2013 | ||||||||
| LastUpdateDate: | 07/05/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 07/05/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | TL-2221 | NJ | N | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 235Z00000X | SL011774 | PA | N | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 235Z00000X | 41YS00750900 | NJ | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 235Z00000X | N | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.