Provider Demographics
NPI:1104821479
Name:HALL, RODERICK SEITES (PHD)
Entity type:Individual
Prefix:DR
First Name:RODERICK
Middle Name:SEITES
Last Name:HALL
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1224 10TH ST
Mailing Address - Street 2:STE 208
Mailing Address - City:CORONADO
Mailing Address - State:CA
Mailing Address - Zip Code:92118-3420
Mailing Address - Country:US
Mailing Address - Phone:619-437-0440
Mailing Address - Fax:619-435-6040
Practice Address - Street 1:1224 10TH ST
Practice Address - Street 2:STE 208
Practice Address - City:CORONADO
Practice Address - State:CA
Practice Address - Zip Code:92118-3420
Practice Address - Country:US
Practice Address - Phone:619-437-0440
Practice Address - Fax:619-435-6040
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY15283103TC0700X
CAPSY 15283103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Not Answered103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACP15283Medicare ID - Type Unspecified