Provider Demographics
NPI:1063684637
Name:HALL, BREDA FAYE (LPCC)
Entity type:Individual
Prefix:
First Name:BREDA
Middle Name:FAYE
Last Name:HALL
Suffix:
Gender:F
Credentials:LPCC
Other - Prefix:
Other - First Name:BREDA
Other - Middle Name:FAYE
Other - Last Name:INMAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LPCC
Mailing Address - Street 1:PO BOX 1643
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:MS
Mailing Address - Zip Code:39043-1643
Mailing Address - Country:US
Mailing Address - Phone:601-951-1583
Mailing Address - Fax:
Practice Address - Street 1:1531 HIGHLAND COLONY PKWY
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:MS
Practice Address - Zip Code:39110-7469
Practice Address - Country:US
Practice Address - Phone:601-506-1459
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-24
Last Update Date:2008-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0083571101YM0800X, 101YP1600X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS01-0877337OtherDEPT. OF TREASURY, IRS