Provider Demographics
NPI:1154521292
Name:HALLA-BAUER, HEIDI ANN (PSYD)
Entity type:Individual
Prefix:
First Name:HEIDI
Middle Name:ANN
Last Name:HALLA-BAUER
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 MEDICAL DR
Mailing Address - Street 2:STE 705
Mailing Address - City:LAGRANGE
Mailing Address - State:GA
Mailing Address - Zip Code:30240-4130
Mailing Address - Country:US
Mailing Address - Phone:706-885-0111
Mailing Address - Fax:706-885-0607
Practice Address - Street 1:300 MEDICAL DR
Practice Address - Street 2:STE 705
Practice Address - City:LAGRANGE
Practice Address - State:GA
Practice Address - Zip Code:30240-4130
Practice Address - Country:US
Practice Address - Phone:706-885-0111
Practice Address - Fax:706-885-0607
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-18
Last Update Date:2009-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY003092103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA874147128AMedicaid
GA874147128AMedicaid