Provider Demographics
NPI:1316932916
Name:LANDRETH, HALLIE DENISE (PH D)
Entity type:Individual
Prefix:
First Name:HALLIE
Middle Name:DENISE
Last Name:LANDRETH
Suffix:
Gender:F
Credentials:PH D
Other - Prefix:
Other - First Name:HALLIE
Other - Middle Name:DENISE
Other - Last Name:WILBORNE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PH D
Mailing Address - Street 1:6900 ALDEN DR
Mailing Address - Street 2:90 MDG
Mailing Address - City:FE WARREN AFB
Mailing Address - State:WY
Mailing Address - Zip Code:82005-3906
Mailing Address - Country:US
Mailing Address - Phone:307-773-2998
Mailing Address - Fax:307-773-4721
Practice Address - Street 1:6900 ALDEN DR
Practice Address - Street 2:90 MDG
Practice Address - City:FE WARREN AFB
Practice Address - State:WY
Practice Address - Zip Code:82005-3906
Practice Address - Country:US
Practice Address - Phone:307-773-2998
Practice Address - Fax:307-773-4721
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20041743A103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAD000Medicare UPIN